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Awad AK, Ahmed A, Mathew DM, Varghese KS, Mathew SM, Khaja S, Newell PC, Okoh AK, Hirji S. Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis. J Cardiol 2024; 83:177-183. [PMID: 37611742 DOI: 10.1016/j.jjcc.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has evolved as an alternative to surgical aortic valve replacement (SAVR). In addition to full-sternotomy (FS), recent reports have shown successful minimally-invasive SAVR approaches, including mini-sternotomy (MS) and mini-thoracotomy (MT). This network-meta-analysis (NMA) seeks to provide an outcomes comparison based on these different modalities (MS, MT, TAVR) compared with FS as a reference arm for the management of aortic valve disease. METHODS A comprehensive literature search was performed to identify studies that compared minimally-invasive SAVR (MS/MT) to conventional FS-SAVR, and/or TAVR. Bayesian NMA was performed using the random effects model. Outcomes were pooled as risk ratios (RR) with their 95 % confidence intervals (CIs). Our primary outcomes included 30-day mortality, stroke, acute kidney injury (AKI), major bleeding, new permanent pacemaker (PPM), and paravalvular leak (PVL). We also assessed long-term mortality at the latest follow-up. RESULTS A total of 27,117 patients (56 studies) were included; 10,397 patients had FS SAVR, 9523 had MS, 5487 had MT, and 1710 had TAVR. Compared to FS, MS was associated with statistically-significantly lower rates of 30-day mortality (RR, 0.76, 95%CI 0.59-0.98), stroke (RR, 0.84, 95%CI 0.72-0.97), AKI (RR, 0.76, 95%CI 0.61-0.94), and long-term mortality (RR 0.84, 95%CI 0.72-0.97) at a weighted mean follow-up duration of 10.4 years, while MT showed statistically-significantly higher rates of 30-day PVL (RR, 3.76, 95%CI 1.31-10.85) and major bleeding (RR 1.45; 95%CI 1.08-1.94). TAVR had statistically significant lower rates of 30-day AKI (RR 0.49, 95%CI 0.31-0.77), but showed statistically-significantly higher PPM (RR 2.50; 95%CI 1.60-3.91) and 30-day PVL (RR 12.85, 95%CI 5.05-32.68) compared to FS. CONCLUSIONS MS was protective against 30-day mortality, stroke, AKI, and long-term mortality compared to FS; TAVR showed higher rates of 30-day PVL and PPM but was protective against AKI. Conversely, MT showed higher rates of 30-day PVL and major bleeding. With the emergence of TAVR, the appropriate benchmarks for SAVR comparison in future trials should be the minimally-invasive SAVR approaches to provide clinical equipoise.
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Affiliation(s)
- Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Adham Ahmed
- City University of New York School of Medicine, New York, NY, USA
| | - Dave M Mathew
- City University of New York School of Medicine, New York, NY, USA
| | | | - Serena M Mathew
- City University of New York School of Medicine, New York, NY, USA
| | - Sofia Khaja
- City University of New York School of Medicine, New York, NY, USA
| | - Paige C Newell
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Sameer Hirji
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Elghannam M, Useini D, Moustafine V, Bechtel M, Naraghi H, Strauch JT, Haldenwang PL. Minimally Invasive versus Conventional Aortic Root Surgery: Results of an Intermediate-Volume Center. Thorac Cardiovasc Surg 2024; 72:118-125. [PMID: 37040869 DOI: 10.1055/a-2041-3695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND We evaluate the outcome of aortic root surgery via an upper J: -shaped mini-sternotomy (MS) versus full sternotomy (FS) in an intermediate-volume center. METHODS Between November 2011 and February 2019, 94 consecutive patients underwent aortic root surgery: 62 (66%) patients were operated via a J: -shaped MS (group A) and 32 (34%) patients via FS (group B). The primary endpoints were mortality, major adverse cardiac and cerebral events (MACCE), and reoperation in a 2-year follow-up. The secondary endpoints were perioperative complications and patient's satisfaction with the procedural results. RESULTS Valve sparing root replacement (David procedure) was performed in 13 (21%) of the MS and 7 (22%) of the FS patients. The Bentall procedure in MS versus FS was 49 (79%) versus 25 (78%), respectively. Both groups presented similar mean operation, cardiopulmonary bypass, and cross-clamp times. Postoperative bleeding was 534 ± 300 and 755 ± 402 mL (p = 0.01) in MS and FS, respectively, erythrocyte concentrate substitution was 3 ± 3 and 5.3 ± 4.8 (p = 0.018) in MS and FS, respectively, and pneumonia rates were 0 and 9.4% (p = 0.03) in MS and FS, respectively. The 30-day mortality was 0% in both groups, whereas MACCE was 1.6 and 3% (p = 0.45) in MS and FS, respectively. After 2 years, the mortality and MACCE were 4.6 and 9.5% (p = 0.11) and 4.6 and 0% (p = 0.66) in MS and FS, respectively. The number of patients who were satisfied with the surgical cosmetic results in groups A and B was 53 (85.4%) and 26 (81%), respectively. CONCLUSION Aortic root surgery via MS is a safe alternative to FS even in an intermediate-volume center. It offers a shorter recovery time and similar midterm results.
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Affiliation(s)
- Mahmoud Elghannam
- Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
| | - Dritan Useini
- Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
| | - Vadim Moustafine
- Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
| | - Matthias Bechtel
- Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
| | - Hamid Naraghi
- Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
| | - Justus T Strauch
- Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
| | - Peter Lukas Haldenwang
- Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
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Cammertoni F, Bruno P, Pavone N, Nesta M, Chiariello GA, Grandinetti M, D’Avino S, Sanesi V, D’Errico D, Massetti M. Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study. Braz J Cardiovasc Surg 2024; 39:e20230159. [PMID: 38426432 PMCID: PMC10903361 DOI: 10.21470/1678-9741-2023-0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/30/2023] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting. METHODS We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each. RESULTS The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58). CONCLUSION MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.
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Affiliation(s)
- Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Piergiorgio Bruno
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Natalia Pavone
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Alfonso Chiariello
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Maria Grandinetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | | | - Denise D’Errico
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione
Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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He R, Zhang K, Zhou C, Pei C. Effect of right anterolateral thoracotomy versus median sternotomy on postoperative wound tissue repair in patients with congenital heart disease: A meta-analysis. Int Wound J 2024; 21:e14343. [PMID: 37641209 PMCID: PMC10781613 DOI: 10.1111/iwj.14343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/31/2023] Open
Abstract
Right anterolateral thoracotomy (RAT) and median sternotomy (MS) are two major methods for treatment of congenital cardiac disease. But there are various types of surgery that provide a better operative outcome for the patient. Therefore, we carried out a meta-analysis to investigate the effects of these two methods in the treatment of wound tissue, hospitalization and so on, to find out which surgery method could provide the best short-term effect. In this research, we chose an English controlled trial from 2003 to 2022 to evaluate the influence of right anterolateral thoracotomy and median sternotomy on the short-term outcome of Cardiopulmonary bypass (CPB), time of operation, time spent in the hospital, and the time of scar formation. Our findings suggest that the RAT method was associated with a shorter surgical scars for congenital heart disease operations compared to MS with respect to post-operation scars (WMD, 3.55; 95% CI, 0.04, 7.05; p = 0.05). The RAT method is better suited to the needs of patients who care about their injuries. Nevertheless, in addition to other surgery related factors which might affect post-operative wound healing, we discovered that MS took a shorter time to perform CPB compared with RAT surgery (WMD, - 1.94; 95% CI, -3.39, -0.48; p = 0.009). Likewise, when it comes to the time taken to perform surgery, MS needs less operational time compared to RAT methods (WMD, -12.84; 95% CI, -25.27, -0.42; p = 0.04). On the other hand, the time needed for MS to recover was much longer compared to the RAT (WMD, 0. 60; 95% CI, 0.02, 1.18; p = 0.04). This indicates that while RAT is advantageous in terms of shortening the duration of post-operative scar, it also increases the time needed for surgical operations and CPB.
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Affiliation(s)
- Ruijing He
- Maternal and Child Health Hospital of Hubei ProvinceWuhanChina
| | - Kai Zhang
- Maternal and Child Health Hospital of Hubei ProvinceWuhanChina
| | - Chunlong Zhou
- Maternal and Child Health Hospital of Hubei ProvinceWuhanChina
| | - Chengcheng Pei
- Maternal and Child Health Hospital of Hubei ProvinceWuhanChina
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Fallon JM, Malenka DJ, Ross CS, Ramkumar N, Seshasayee SM, Westbrook BM, Hirashima F, Quinn RD. The Northern New England Rapid Deployment Valve Experience: Survival and Procedural Outcomes From 2015 to 2021. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:54-63. [PMID: 38318656 DOI: 10.1177/15569845231223504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
OBJECTIVE The optimal approach and choice of initial aortic valve replacement (AVR) is evolving in the growing era of transcatheter AVR. Further survival and hemodynamic data are needed to compare the emerging role of rapid deployment (rdAVR) versus stented (sAVR) valve options for AVR. METHODS The Northern New England Cardiovascular Database was queried for patients undergoing either isolated AVR or AVR + coronary artery bypass grafting (CABG) with rdAVR or sAVR aortic valves between 2015 and 2021. Exclusion criteria included endocarditis, mechanical valves, dissection, emergency case status, and prior sternotomy. This resulted in a cohort including 1,616 sAVR and 538 rdAVR cases. After propensity weighting, procedural characteristics, hemodynamic variables, and survival outcomes were examined. RESULTS The breakdown of the overall cohort (2,154) included 1,164 isolated AVR (222 rdAVR, 942 sAVR) and 990 AVR + CABG (316 rdAVR, 674 sAVR). After inverse propensity weighting, cohorts were well matched, notable only for more patients <50 years in the sAVR group (4.0% vs 1.9%, standardized mean difference [SMD] = -0.12). Cross-clamp (89 vs 64 min, SMD = -0.71) and cardiopulmonary bypass (121 vs 91 min, SMD = -0.68) times were considerably longer for sAVR versus rdAVR. Immediate postreplacement aortic gradient decreased with larger valve size but did not differ significantly between comparable sAVR and rdAVR valve sizes or overall (6.5 vs 6.7 mm Hg, SMD = 0.09). Implanted rdAVR tended to be larger with 51% either size L or XL versus 37.4% of sAVR ≥25 mm. Despite a temporal decrease in pacemaker rate within the rdAVR cohort, the overall pacemaker frequency was less in sAVR versus rdAVR (4.4% vs 7.4%, SMD = 0.12), and significantly higher rates were seen in size L (10.3% vs 3.7%, P < 0.002) and XL (15% vs 5.6%, P < 0.004) rdAVR versus sAVR. No significant difference in major adverse cardiac events (4.6% vs 4.6%, SMD = 0.01), 30-day survival (1.5% vs 2.6%, SMD = 0.08), or long-term survival out to 4 years were seen between sAVR and rdAVR. CONCLUSIONS Rapid deployment valves offer a safe alternative to sAVR with significantly decreased cross-clamp and cardiopulmonary bypass times. Despite larger implantation sizes, we did not appreciate a comparative difference in immediate postoperative gradients, and although pacemaker rates are improving, they remain higher in rdAVR compared with sAVR. Longer-term hemodynamic and survival follow-up are needed.
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Affiliation(s)
- John M Fallon
- Department of Cardiac Surgery, Maine Medical Center, Portland, ME, USA
| | - David J Malenka
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Cathy S Ross
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Niveditta Ramkumar
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | | | | | - Reed D Quinn
- Department of Cardiac Surgery, Maine Medical Center, Portland, ME, USA
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Kirmani BH, Jones SG, Muir A, Malaisrie SC, Chung DA, Williams RJ, Akowuah E. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev 2023; 12:CD011793. [PMID: 38054555 PMCID: PMC10698838 DOI: 10.1002/14651858.cd011793.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Aortic valve disease is a common condition easily treatable with cardiac surgery. This is conventionally performed by opening the sternum ('median sternotomy') and replacing the valve under cardiopulmonary bypass. Median sternotomy is well tolerated, but as less invasive options become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access have raised safety concerns with regard to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity. This is an update of a Cochrane review first published in 2017, with seven new studies. OBJECTIVES To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement. SEARCH METHODS We performed searches of CENTRAL, MEDLINE and Embase from inception to August 2021, with no language limitations. We also searched two clinical trials registries and manufacturers' websites. We reviewed references of primary studies to identify any further studies of relevance. SELECTION CRITERIA We included randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, transapical, transfemoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. We determined the certainty of evidence using the GRADE methodology and summarised results of patient-relevant outcomes in a summary of findings table. MAIN RESULTS The review included 14 trials with 1395 participants. Most studies had at least two domains at high risk of bias. We analysed 14 outcomes investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy. Upper hemi-sternotomy may have little to no effect on mortality versus full median sternotomy (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.45 to 1.94; 10 studies, 985 participants; low-certainty evidence). Upper hemi-sternotomy for aortic valve replacement may increase cardiopulmonary bypass time slightly, although the evidence is very uncertain (mean difference (MD) 10.63 minutes, 95% CI 3.39 to 17.88; 10 studies, 1043 participants; very low-certainty evidence) and may increase aortic cross-clamp time slightly (MD 6.07 minutes, 95% CI 0.79 to 11.35; 12 studies, 1235 participants; very low-certainty evidence), although the evidence is very uncertain. Most studies had at least two domains at high risk of bias. Postoperative blood loss was probably lower in the upper hemi-sternotomy group (MD -153 mL, 95% CI -246 to -60; 8 studies, 767 participants; moderate-certainty evidence). Low-certainty evidence suggested that there may be no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.19, 95% CI -0.43 to 0.04; 5 studies, 649 participants). Upper hemi-sternotomy may result in little to no difference in quality of life (MD 0.03 higher, 95% CI 0 to 0.06 higher; 4 studies, 624 participants; low-certainty evidence). Two studies reporting index admission costs concluded that limited sternotomy may be more costly at index admission in the UK National Health Service (MD 1190 GBP more, 95% CI 420 GBP to 1970 GBP, 2 studies, 492 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence was of very low to moderate certainty. Sample sizes were small and underpowered to demonstrate differences in some outcomes. Clinical heterogeneity was also noted. Considering these limitations, there may be little to no effect on mortality. Differences in extracorporeal support times are uncertain, comparing upper hemi-sternotomy to full sternotomy for aortic valve replacement. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from also performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality of life analyses to be included as end points, as well as quantitative measures of physiological reserve.
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Affiliation(s)
- Bilal H Kirmani
- Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Sion G Jones
- Department of Cardiac Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Andrew Muir
- Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University, Chicago, IL, USA
| | | | | | - Enoch Akowuah
- Academic Cardiovascular Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
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Irace FG, Chirichilli I, Russo M, Ranocchi F, Bergonzini M, Lio A, Nicolò F, Musumeci F. Aortic Valve Replacement: Understanding Predictors for the Optimal Ministernotomy Approach. J Clin Med 2023; 12:6717. [PMID: 37959183 PMCID: PMC10647482 DOI: 10.3390/jcm12216717] [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: 08/30/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION The most common minimally invasive approach for aortic valve replacement (AVR) is the partial upper mini-sternotomy. The aim of this study is to understand which preoperative computed tomography (CT) features are predictive of longer operations in terms of cardio-pulmonary bypass timesand cross-clamp times. METHODS From 2011 to 2022, we retrospectively selected 246 patients which underwent isolated AVR and had a preoperative ECG-gated CT scan. On these patients, we analysed the baseline anthropometric characteristics and the following CT scan parameters: aortic annular dimensions, valve calcium score, ascending aorta length, ascending aorta inclination and aorta-sternum distance. RESULTS We identified augmented body surface area (>1.9 m2), augmented annular diameter (>23 mm), high calcium score (>2500 Agatson score) and increased aorta-sternum distance (>30 mm) as independent predictors of elongated operation times (more than two-fold). CONCLUSIONS Identifying the preoperative predictive factors of longer operations can help surgeons select cases suitable for minimally invasive approaches, especially in a teaching context.
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Affiliation(s)
| | | | - Marco Russo
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Viale Gianicolense 87, 00151 Rome, Italy (A.L.); (F.M.)
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Gerfer S, Eghbalzadeh K, Brinkschröder S, Djordjevic I, Rustenbach C, Rahmanian P, Mader N, Kuhn E, Wahlers T. Is It Reasonable to Perform Isolated SAVR by Residents in the TAVI Era? Thorac Cardiovasc Surg 2023; 71:376-386. [PMID: 34808679 DOI: 10.1055/s-0041-1736206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The role of conventional surgical aortic valve replacement (SAVR) is increasingly questioned since the indication for transcatheter aortic valve implantations (TAVIs) is currently extended. While the number of patients referred to SAVR decreases, it is unclear if SAVR should be performed by junior resident surgeons in the course of a heart surgeons training. METHODS Patients with isolated aortic valve replacement (AVR) were analyzed with respect to the surgeon's qualification. AVR performed by resident surgeons was compared with AVR by senior surgeons. The collective was analyzed with respect to clinical short-term outcomes comparing full sternotomy (FS) with minimally invasive surgery and ministernotomy (MS) with right anterior thoracotomy (RAT) after a 1:1 propensity score matching. RESULTS The 30-day all-cause mortality was 2.3 and 3.4% for resident versus senior AVR groups, cerebrovascular event rates were 1.1 versus 2.6%, and no cases of significant paravalvular leak were detected. Clinical short-term outcomes between FS and minimally invasive access, as well after MS and RAT were comparable. CONCLUSION Our current data show feasibility and safety of conventional SAVR procedure performed by resident surgeons in the era of TAVI. Minimally invasive surgery should be trained and performed in higher volumes early in the educational process as it is a safe treatment option.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Sarah Brinkschröder
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
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Dahaba AA. Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH). BMC Anesthesiol 2023; 23:172. [PMID: 37210500 PMCID: PMC10199628 DOI: 10.1186/s12871-023-02140-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Bochdalek congenital diaphragmatic hernia (CDH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the developing lung parenchyma and lung hypoplasia. We describe a case of an adult patient with a Bochdalek hernia who underwent minimally invasive right thoracotomy Perceval bioprosthetic aortic valve replacement (AVR) requiring one-lung ventilation (OLV) on the side of the hernia. This is a complex and challenging case that brings up numerous thought-provoking anesthetic implications. To the best of our knowledge, a Pubmed search did not reveal any publication to date of difficult airway management in an adult patient with CDH. CASE PRESENTATION The first major problem encountered was patient's crus habitus anatomical condition (exceedingly ventrally displaced trachea) Mallampati Class IV and Cormack-Lehane grade IV extremely difficult endotracheal intubation. Neither glottis nor epiglottis was visible on laryngoscopy; resulting in failed placement of the double-lumen endobronchial tube (DLT) following numerous attempts. The DLT was eventually placed via GlideScope videolaryngoscopy. Whereas the endobroncheal right lung block for left OLV was successfully placed using fiberopticscopy. The crus habitus encroached on OLV tidal volume by the cranially displaced ascending colon and left kidney. Anesthesia was maintained with remifentanil /sevoflurane; adjusted to maintain bispectral index (BIS) at 40-60. Digitally recorded BIS was 38-62 except when BIS precipitously declined to 14-38 (SR, suppression ratio < 10) for 25 min after termination of the cardiopulmonary bypass. CONCLUSIONS We report a case essentially dealing with an anatomically distorted difficult airway in a patient with left Bochdalek CDH undergoing a complex AVR. We describe anesthetic difficulties and unforeseen issues encountered; such as an extremely difficult DLT placement.
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Affiliation(s)
- Ashraf A Dahaba
- Department of Anaesthesiology and Intensive Care Medicine, Suez Canal University, Ismailia, 41522, Egypt.
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10
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Bonacchi M, Dokollari A, Parise O, Sani G, Prifti E, Bisleri G, Gelsomino S. Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery. J Thorac Cardiovasc Surg 2023; 165:1022-1032.e2. [PMID: 33994208 DOI: 10.1016/j.jtcvs.2021.03.125] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 03/20/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Ministernotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques. METHODS The data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067). RESULTS After propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan-Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087). CONCLUSIONS Minimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.
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Affiliation(s)
- Massimo Bonacchi
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy.
| | - Aleksander Dokollari
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Orlando Parise
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Guido Sani
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy; Cardiac Surgery, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Edvin Prifti
- Division of Cardiac Surgery, University Hospital Center of Tirana, Tirana, Albania
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sandro Gelsomino
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
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11
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Vohra HA, Salmasi MY, Mohamed F, Shehata M, Bahrami B, Caputo M, Deshpande R, Bapat V, Bahrami T, Birdi I, Zacharias J. Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting. Open Heart 2023; 10:e002194. [PMID: 37001910 PMCID: PMC10069572 DOI: 10.1136/openhrt-2022-002194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/27/2023] [Indexed: 04/04/2023] Open
Abstract
The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.
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Affiliation(s)
| | | | | | | | | | | | | | - Vinayak Bapat
- Cardiovascular Directorate, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Inderpaul Birdi
- Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Joseph Zacharias
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
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12
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Luo ZR, Chen YX, Chen LW. Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients. J Cardiothorac Surg 2022; 17:135. [PMID: 35641935 PMCID: PMC9158371 DOI: 10.1186/s13019-022-01890-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Excellent partial upper sternotomy outcomes have been reported for patients undergoing aortic surgery, but whether this approach is particularly beneficial to obese patients remains to be established. This study was developed to explore the outcomes of aortic surgical procedures conducted via a partial upper sternotomy or a full median sternotomy approach in obese patients. Methods We retrospectively examined consecutive acute type A aortic dissection patients who underwent aortic surgery in our hospital between January 2015 to January 2021. Patients were divided into two groups based on body mass index: ‘non-obese’ and ‘obese’. We then further stratified patients in the obese and non-obese groups into partial upper sternotomy and full median sternotomy groups, with outcomes between these two sternotomy groups then being compared within and between these two body mass index groups. Results In total, records for 493 patients that had undergone aortic surgery were retrospectively reviewed, leading to the identification of 158 consecutive obese patients and 335 non-obese patients. Overall, 88 and 70 obese patients underwent full median sternotomy and partial upper sternotomy, respectively, while 180 and 155 non-obese patients underwent these respective procedures. There were no differences between the full median sternotomy and partial upper sternotomy groups within either BMI cohort with respect to preoperative baseline indicators and postoperative complications. Among non-obese individuals, the partial upper sternotomy approach was associated with reduced ventilation time (P = 0.003), shorter intensive care unit stay (P = 0.017), shorter duration of hospitalization (P = 0.001), and decreased transfusion requirements (Packed red blood cells: P < 0.001; Fresh frozen plasma: P < 0.001). Comparable findings were also evident among obese patients. Conclusions Obese aortic disease patients exhibited beneficial outcomes similar to those achieved for non-obese patients via a partial upper sternotomy approach which was associated with significant reductions in the duration of intensive care unit residency, duration of hospitalization, ventilator use, and transfusion requirements. This surgical approach should thus be offered to aortic disease patients irrespective of their body mass index.
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Affiliation(s)
- Zeng-Rong Luo
- Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yi-Xing Chen
- Department of Cardiology, Nan Ping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People's Republic of China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China.
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13
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Sef D, Bahrami T, Raja SG, Klokocovnik T. Current trends in minimally invasive valve‐sparing aortic root replacement—Best available evidence. J Card Surg 2022; 37:1684-1690. [PMID: 35348237 DOI: 10.1111/jocs.16453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/20/2022] [Accepted: 03/05/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Davorin Sef
- Department of Cardiac Surgery, Harefield Hospital, Royal Brompton and Harefield Hospitals Part of Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Toufan Bahrami
- Department of Cardiac Surgery, Harefield Hospital, Royal Brompton and Harefield Hospitals Part of Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Shahzad G. Raja
- Department of Cardiac Surgery, Harefield Hospital, Royal Brompton and Harefield Hospitals Part of Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Tomislav Klokocovnik
- Department of Cardiovascular Surgery University Hospital Center Ljubljana Ljubljana Slovenia
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14
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Panagiotopoulos I, Kotsopoulos N, Verras GI, Mulita F, Katinioti A, Koletsis E, Triantafyllou K, Yfantopoulos J. Perceval S, sutureless aortic valve: cost-consequence analysis. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2022; 19:22-27. [PMID: 35414814 PMCID: PMC8981134 DOI: 10.5114/kitp.2022.114551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/28/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Sutureless aortic valve prostheses have the potential of shortening ischemic time. AIM We conducted the present study to assess the clinical and economic impact of the biological, sutureless, self-expanding Perceval S valve since the effect of shortened operative times on hospital costs remains unclear. MATERIAL AND METHODS This is a retrospective analysis. From January 2018 to January 2019, 29 patients underwent isolated aortic valve replacement with the Crown PRT bioprosthetic Aortic Valve, whereas 35 patients underwent aortic valve replacement with Perceval S (auto-expanded, sutureless, bioprosthesis). Preoperative data, hospital outcome, and health care resource consumption were compared, using χ2 and t-test. RESULTS Aortic cross-clamp, cardiopulmonary bypass, and operation times were significantly shorter in the Perceval S group (p < 0.001). Patients in the sutureless group required blood transfusion less frequently (p = 0.03) and had a shorter intensive care unit (ICU) stay (p = 0.01). Hospital stay (p = 0.57) and pacemaker implantation were similar between groups. The reduction of aortic cross-clamp, extracorporeal circulation times, and ICU stay resulted in reduced resource consumption in the sutureless group. CONCLUSIONS The use of the Perceval S valve is clinically safe and effective. A shorter procedural time in the sutureless group is associated with better clinical outcomes and reduced hospital costs.
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Affiliation(s)
- Ioannis Panagiotopoulos
- Department of Cardiothoracic Surgery, General University, Hospital of Patras, Patras, Greece
| | - Nikolaos Kotsopoulos
- Division of Health Economics, Global Market Access Solutions, St-Prex, Switzerland
| | | | - Francesk Mulita
- Department of Surgery, General University, Hospital of Patras, Patras, Greece
| | - Anastasia Katinioti
- Cardiology Unit, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Efstratios Koletsis
- Department of Cardiothoracic Surgery, General University, Hospital of Patras, Patras, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, 2nd Department of Internal Medicine-Propaedeutic, National and Kapodistrian University of Athens, “Attikon” University General Hospital, Athens, Greece
| | - John Yfantopoulos
- MBA – Health Department of Economics, National and Kapodistrian University of Athens, Athens, Greece
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15
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First case of a patient with left Bochdalek congenital diaphragmatic hernia and congenital bicuspid aortic valve stenosis undergoing Perceval bioprosthetic aortic valve replacement via mini-thoracotomy one-lung anesthesia. Asian J Surg 2022; 45:1742-1743. [PMID: 35184960 DOI: 10.1016/j.asjsur.2022.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 11/23/2022] Open
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16
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Wilson TW, Horns JJ, Sharma V, Goodwin ML, Kagawa H, Pereira SJ, McKellar SH, Selzman CH, Glotzbach JP. Minimally Invasive versus Full Sternotomy SAVR in the Era of TAVR: An Institutional Review. J Clin Med 2022; 11:jcm11030547. [PMID: 35159998 PMCID: PMC8836475 DOI: 10.3390/jcm11030547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/04/2022] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
In the era of advancing transcatheter aortic valve replacement (TAVR) technology, traditional open surgery remains a valuable intervention for patients who are not TAVR candidates. We sought to compare perioperative variables and postoperative outcomes of minimally invasive and full sternotomy surgical aortic valve replacement (SAVR) at a single institution. A retrospective analysis of 113 patients who underwent isolated SAVR via full sternotomy or upper hemi-sternotomy between January 2015 and December 2019 at the University of Utah Hospital was performed. Preoperative comorbidities and demographic information were not different among groups, with the exception of diabetes, which was significantly more common in the full sternotomy group (p = 0.01). Median procedure length was numerically shorter in the minimally invasive group but was not significant following the Bonferroni correction (p = 0.047). Other perioperative variables were not significantly different. The two groups showed no difference in the incidence of postoperative adverse events (p = 0.879). As such, minimally invasive SAVR via hemi-sternotomy remains a safe and effective alternative to full sternotomy for patients who meet the criteria for aortic valve replacement.
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Affiliation(s)
- Tyler W. Wilson
- School of Medicine, University of Utah, Salt Lake City, UT 84132, USA;
| | - Joshua J. Horns
- Department of Surgery, University of Utah, Salt Lake City, UT 84132, USA;
| | - Vikas Sharma
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT 84132, USA; (V.S.); (M.L.G.); (H.K.); (S.J.P.); (C.H.S.)
| | - Matthew L. Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT 84132, USA; (V.S.); (M.L.G.); (H.K.); (S.J.P.); (C.H.S.)
| | - Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT 84132, USA; (V.S.); (M.L.G.); (H.K.); (S.J.P.); (C.H.S.)
| | - Sara J. Pereira
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT 84132, USA; (V.S.); (M.L.G.); (H.K.); (S.J.P.); (C.H.S.)
| | - Stephen H. McKellar
- Cardiovascular and Thoracic Surgery, Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA;
| | - Craig H. Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT 84132, USA; (V.S.); (M.L.G.); (H.K.); (S.J.P.); (C.H.S.)
| | - Jason P. Glotzbach
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT 84132, USA; (V.S.); (M.L.G.); (H.K.); (S.J.P.); (C.H.S.)
- Correspondence:
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17
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Zallé I, Son M, El-Alaoui M, Nijimbéré M, Boumzebra D. Minimally invasive and full sternotomy in aortic valve replacement: a comparative early operative outcomes. Pan Afr Med J 2021; 40:68. [PMID: 34804336 PMCID: PMC8590260 DOI: 10.11604/pamj.2021.40.68.28008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction aortic valve replacement is usually performed through a median full sternotomy (MFS) in our department. Minimally invasive aortic valve replacement (MIAVR) has been recently adopted as a new approach. According to the literature, the superiority of MIAVR is controversial. In this study we report early post-operative outcomes in MIAVR compared with MFS access with reference to blood Loss, wound infections, post-operative recovery, morbidity and mortality. Methods this study was a prospective data collection from 36 consecutive patients undergoing isolated valve replacement. Two population study was identified, MIAVR group (group I n=18) and MFS group (group II n=18). Patients´ data were collected and analyzed using IBM SPSS statistics 21 software and Khi2 test has been used to compare the variables. The study variables are presented as numbers, percentage, median with interquartile range. Pre-operative planning was performed so that to obtain similar characteristics. Results in group I, upper mini-sternotomy was used in 12 patients and right mini-thoracotomy in 6 patients. There was no difference in term of mortality and morbidity. MIAVR was associated with longer CPB time (93.25 (58-161) vs 131 (75-215) mins, P=0.047) with no significant difference in term of ACC time (81 (33-162) vs 58.8 (59-102) mins P=0.158). MIAVR´ Patients had likely lower incidence of red blood cells transfusion (16.7 vs 52.3%) without significant difference about post-operative haemoglobin (P = 0,330). Patients in group I had shorter ventilation time (2.35 (1-12) vs 9.3 (1-48) hours P < 0.01), shorter ICU stay (2.44 (1-8) vs 4.25 (1-9) days, P = 0,024). The length of hospital stay was shorter, 6.5 (5-9) days in group I vs 7.4 (6-11), P=0.0274. Length of chest tube stay was shorter in group I (mean 1.53 vs 2.4 days, P=0,033). Wound infections were not found in both groups. Conclusion minimally invasive aortic valve replacement is associated with less blood loss, faster post-operative recovery faster post-operative recovery but increase operation time.
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Affiliation(s)
- Issaka Zallé
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Moussa Son
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Mohamed El-Alaoui
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Macédoine Nijimbéré
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Drissi Boumzebra
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
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18
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Haunschild J, van Kampen A, von Aspern K, Misfeld M, Davierwala P, Saeed D, Borger MA, Etz CD. Supracommissural replacement of the ascending aorta and the aortic valve via partial versus full sternotomy-a propensity-matched comparison in a high-volume centre. Eur J Cardiothorac Surg 2021; 61:479-487. [PMID: 34453828 DOI: 10.1093/ejcts/ezab373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/26/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Full sternotomy (FS) is the common surgical access for patients undergoing open aortic valve replacement (AVR) with concomitant supracommissural replacement of the tubular ascending aorta. Since minimally invasive approaches are being used with increasing frequency in cardiac surgery, the aim of this study was to compare outcomes of patients undergoing AVR with supracommissural replacement of the tubular ascending aorta via FS versus partial upper sternotomy (PS). METHODS We included all patients who underwent elective AVR with concomitant supracommissural replacement of the tubular ascending aorta at our institution between 2000 and 2015. Exclusion criteria were emergency surgery, other major concomitant procedures and reoperations. After 2:1 propensity score matching, outcomes of patients with PS and FS were compared. RESULTS A total of 652 consecutive patients were included, 117 patients operated via PS and 234 patients operated via FS. Cardiopulmonary bypass time and aortic cross-clamp time of the PS and FS groups were 89 vs 92 min (P = 0.2) and 65 vs 70 min (P = 0.3), respectively. Postoperative morbidity was low and there were no significant differences in postoperative outcomes between patient groups. In-hospital mortality was 1.7% in the PS vs 0.4% in the FS group (P = 0.3). Kaplan-Meier analysis revealed no difference in mid-term survival (P = 0.3). Reoperation rates for valve or aortic complications were very low with no significant difference between groups. CONCLUSIONS In a high-volume centre with extensive experience in minimally invasive cardiac surgery, AVR with concomitant supracommissural replacement of the tubular ascending aorta via PS results in similar outcomes with regard to safety and longevity when compared to conventional FS.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Antonia van Kampen
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Martin Misfeld
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Cardiac Surgery, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Institute of Academic Surgery, RPAH, Sydney, NSW, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | - Piroze Davierwala
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Diyar Saeed
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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19
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Cammertoni F, Bruno P, Pavone N, Farina P, Mazza A, Iafrancesco M, Nesta M, Chiariello GA, Spalletta C, Cavaliere F, Calabrese M, D'Angelo GA, Sanesi V, Conti F, D'Errico D, Massetti M. Influence of cardiopulmonary bypass set-up and management on clinical outcomes after minimally invasive aortic valve surgery. Perfusion 2021; 36:679-687. [PMID: 34080484 DOI: 10.1177/02676591211023301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Minimally invasive aortic valve replacement (MIAVR) requires changes in cannulation strategy and cardiopulmonary bypass (CPB) management when compared to the conventional approach (CAVR). We aimed at evaluating if these differences could influence perfusion-related quality parameters and impair postoperative outcomes. METHODS Overall, 339 consecutive patients underwent MIAVR or CAVR between 2014 and 2020 and were analyzed retrospectively. To account for baseline differences, a propensity-matching analysis was performed, obtaining two groups of 97 patients each. RESULTS MIAVR group had longer CPB time [107 (95-120) vs 95 (86-105) min, p = .003] than CAVR group. Of note, average pump flow rate index [2.4 (2.2-2.5) vs 2.7 (2.4-2.8) l/min/m2, p = .004] was lower in the MIAVR group. Mean arterial pressure was 73 = 9 mmHg vs 62 = 11 mmHg for the MIAVR and CAVR group, respectively (p < .001). Cell-salvaged blood was most commonly used in the MIAVR group (25.8% vs 11.3%, p = .02). Finally, CPB temperature was 32.8°C (32.1-34.8) for MIAVR group vs 34.9°C (33.2-36.1) for the CAVR group (p = .02). Postoperative complications were similar between groups. CONCLUSIONS In conclusion, despite differences in CPB parameters in patients undergoing CAVR and MIAVR, the incidences of adverse outcomes were similar. However, compared to CAVR, MIAVR was associated with shorter durations of mechanical ventilation and hospital stay as well as less transfusion of blood products.
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Affiliation(s)
- Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
| | - Piergiorgio Bruno
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
| | - Natalia Pavone
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Piero Farina
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Andrea Mazza
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Mauro Iafrancesco
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Giovanni A Chiariello
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
| | - Claudio Spalletta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Franco Cavaliere
- Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Sciences, Intensive Care Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Maria Calabrese
- Department of Cardiovascular Sciences, Intensive Care Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | | | | | - Francesco Conti
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Denise D'Errico
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
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20
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Fatehi Hassanabad A, Aboelnazar N, Maitland A, Holloway DD, Adams C, Kent WDT. Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center. J Card Surg 2021; 36:2365-2372. [PMID: 34002895 DOI: 10.1111/jocs.15571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The goal of this manuscript was to report the clinical outcomes of the initial series of 100 consecutive Right Anterior Mini Thoracotomy (RAMT) aortic valve replacement (AVR) implantations at a Canadian Center. METHODS This retrospective study reported the clinical outcomes of the first 100 patients who underwent the RAMT approach for isolated surgical AVR in Calgary, Canada, between 2016 and 2020. Primary outcomes were death within 30 days of surgery and disabling stroke. Secondary outcomes included surgical times, the need for permanent pacemaker (PPM), incidence of postoperative blood transfusion in the intensive care unit (ICU), postsurgical atrial fibrillation (AF), length of ICU/hospital stay, postsurgical AF, residual paravalvular leak (PVL), postoperative transvalvular gradient, need for postsurgical intravenous opioids, duration of invasive ventilation in the ICU, and chest tube output in the first 12 h postsurgery. RESULTS In this study, 54 patients were male, and the average age of the cohort was 72 years. Mortality within 30 days of surgery was 1% with no disabling postoperative strokes. Mean cardiopulmonary bypass and cross clamp was 84 and 55 min, respectively. PPM rate was 3%, incidence of blood transfusion in the ICU was 4%, and the rate of postoperative AF was 23%. Median length of ICU and hospital stay was 1 and 5 days, respectively. Rate of mild or greater residual PVL was 3%, while the average residual transvalvular mean gradient was 8.5 mmHg. CONCLUSION The sternum-sparing RAMT approach can be safely integrated into surgical practice as a minimally invasive alternative for isolated AVR, and can reduce postoperative bleeding and narcotic requirements.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Nader Aboelnazar
- Division of Cardiac Surgery, Department of Surgery, London Health Sciences Center, Western University, London, Ontario, Canada
| | - Andrew Maitland
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Daniel D Holloway
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Corey Adams
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - William D T Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
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21
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Kim E, Kim JB. Suspending Commissural Sutures for Aortic Valve Exposure in Minithoracotomy Aortic Valve Replacement. J Chest Surg 2021; 54:551-553. [PMID: 33975984 PMCID: PMC8646080 DOI: 10.5090/jcs.21.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/01/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022] Open
Abstract
Although it is attractive, a limitation of aortic valve (AV) replacement (AVR) through a mini-thoracotomy approach (mini-AVR) is the limited exposure of the AV. Here, we present a simple exposure technique named “suspending commissural sutures” for a more efficient mini-AVR. The technique involves making 3 half-depth stitches with 1-0 silk at each of the commissures, which are anchored to each corresponding pericardial surface. These stitches are tightened up so that the aortic root is axially expanded and is pulled upward. The technique of suspending commissural stitches seems to offer reasonable exposure of the AV in mini-AVR, and shows excellent early surgical outcomes.
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Affiliation(s)
- Eunji Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Abstract
Since their introduction, it has been demonstrated that minimally invasive aortic valve replacement (MIAVR) approaches are safe and effective for the treatment of aortic valve diseases. To date, the main advantage of these approaches is represented by the reduced surgical trauma, with a subsequent reduced complication rate and faster recovery. This makes such approaches an appealing choice also for frail patients [obese, aged, chronic obstructive pulmonary disease (COPD)]. The standardization of the minimally invasive techniques, together with the implementation of preoperative workup and anesthesiological intra- and post-operative care, led to an amelioration of surgical results and reduction of surgical times. Moreover, the improvement of surgical technology and the introduction of new devices such as sutureless and rapid deployment (SURD) valves, has helped the achievement of comparable results to traditional surgery. However, transcatheter technologies are nowadays more and more important in the treatment of aortic valve disease, also in low risk patients. For this reason surgeons should put new efforts for further reducing the surgical trauma in the future, even taking inspiration from other disciplines. In this review, we aim to present a review of literature evidences regarding minimally invasive treatment of aortic diseases, also reflecting our personal experience with MIAVR techniques. This review could represent a tool for a well-structured patient assessment and preoperative planning, in order to safely carrying out an MIAVR procedure with satisfactory outcomes.
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Affiliation(s)
- Lorenzo Di Bacco
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
| | - Antonio Miceli
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
| | - Mattia Glauber
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
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23
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Klop IDG, van Putte BP, Kloppenburg GTL, Sprangers MAG, Nieuwkerk PT, Klein P. Comparing quality of life and postoperative pain after limited access and conventional aortic valve replacement: Design and rationale of the LImited access aortic valve replacement (LIAR) trial. Contemp Clin Trials Commun 2021; 21:100700. [PMID: 33506139 PMCID: PMC7815656 DOI: 10.1016/j.conctc.2021.100700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/04/2020] [Accepted: 01/01/2021] [Indexed: 11/21/2022] Open
Abstract
Background Surgical aortic valve replacement (SAVR) via limited access approaches (‘mini-AVR’) have proven to be safe alternative for the surgical treatment of aortic valve disease. However, it remains unclear whether these less invasive approaches are associated with improved quality of life and/or reduced postoperative pain when compared to conventional SAVR via full median sternotomy (FMS). Study design The LImited access Aortic valve Replacement (LIAR) trial is a single-center, single blind randomized controlled clinical trial comparing 2 arms of 80 patients undergoing limited access SAVR via J-shaped upper hemi-sternotomy (UHS) or conventional SAVR through FMS. In all randomized patients, the diseased native aortic valve is planned to be replaced with a rapid deployment stented bioprosthesis. Patients unwilling or unable to participate in the randomized trial will be treated conventionally via SAVR via FMS and with implantation of a sutured valve prosthesis. These patients will participate in a prospective registry. Study methods Primary outcome is improvement in cardiac-specific quality of life, measured by two domains of the Kansas City Cardiomyopathy Questionnaire up to one year after surgery. Secondary outcomes include, but are not limited to: generic quality of life measured with the Short Form-36, postoperative pain, perioperative (technical success rate, operating time) and postoperative outcomes (30-day and one-year mortality), complication rate and hospital length of stay. Conclusion The LIAR trial is designed to determine whether a limited access approach for SAVR (‘mini-AVR’) is associated with improved quality of life and/or reduced postoperative pain compared with conventional SAVR through FMS. The study is registered at ClinicalTrials.gov, number NCT04012060.
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Affiliation(s)
- Idserd D G Klop
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Bart P van Putte
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands.,Department of Cardiothoracic Surgery, AMC Heart Centre, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam University Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam University Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Patrick Klein
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
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24
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Mikus E, Calvi S, Brega C, Zucchetta F, Tripodi A, Pin M, Manfrini M, Cimaglia P, Masiglat J, Albertini A. Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller? J Card Surg 2020; 36:582-588. [PMID: 33345384 DOI: 10.1111/jocs.15267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. METHODS From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected. RESULTS Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. CONCLUSIONS Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.
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Affiliation(s)
- Elisa Mikus
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Simone Calvi
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Carlotta Brega
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Fabio Zucchetta
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Alberto Tripodi
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Maurizio Pin
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Marco Manfrini
- Biostatistics and Epidemiology Unit, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Paolo Cimaglia
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Joyce Masiglat
- Department of Cardio-Thoracic and Vascular Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Alberto Albertini
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
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25
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Cammertoni F, Bruno P, Rosenhek R, Pavone N, Farina P, Mazza A, Iafrancesco M, Nesta M, Chiariello GA, Comerci G, Pasquini A, Cavaliere F, Guarneri S, Marzetti E, Rabini A, Piarulli A, Sanesi V, D'Errico D, Massetti M. Minimally Invasive Aortic Valve Surgery in Octogenarians: Reliable Option or Fallback Solution? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 16:34-42. [PMID: 33320024 DOI: 10.1177/1556984520974467] [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: 11/17/2022]
Abstract
OBJECTIVE Aortic valve disease is more and more common in western countries. While percutaneous approaches should be preferred in older adults, previous reports have shown good outcomes after surgery. Moreover, advantages of minimally invasive approaches may be valuable for octogenarians. We sought to compare outcomes of conventional aortic valve replacement (CAVR) versus minimally invasive aortic valve replacement (MIAVR) in octogenarians. METHODS We retrospectively collected data of 75 consecutive octogenarians who underwent primary, elective, isolated aortic valve surgery through conventional approach (41 patients, group CAVR) or partial upper sternotomy (34 patients, group MIAVR). RESULTS Mean age was 81.9 ± 0.9 and 82.3 ± 1.1 years in CAVR and MIAVR patients, respectively (P = 0.09). MIAVR patients had lower 24-hour chest drain output (353.4 ± 207.1 vs 501.7 ± 229.9 mL, P < 0.01), shorter mechanical ventilation (9.6 ± 2.4 vs 11.3 ± 2.3 hours, P < 0.01), lower need for blood transfusions (35.3% vs 63.4%, P = 0.02), and shorter hospital stay (6.8 ± 1.6 vs 8.3 ± 4.3 days, P < 0.01). Thirty-day mortality was zero in both groups. Survival at 1, 3, and 5 years was 89.9%, 80%, and 47%, respectively, in the CAVR group, and 93.2%, 82.4%, and 61.8% in the MIAVR group, with no statistically significant differences (log-rank test, P = 0.35). CONCLUSIONS Aortic valve surgery in older patients provided excellent results, as long as appropriate candidates were selected. MIAVR was associated with shorter mechanical ventilation, reduced blood transfusions, and reduced hospitalization length, without affecting perioperative complications or mid-term survival.
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Affiliation(s)
- Federico Cammertoni
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Piergiorgio Bruno
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Raphael Rosenhek
- 27271 Department of Cardiology, Vienna General Hospital, Medical University of Vienna, Austria
| | - Natalia Pavone
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Piero Farina
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Andrea Mazza
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Mauro Iafrancesco
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Marialisa Nesta
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,60234 Catholic University of the Sacred Heart, Rome, Italy
| | | | - Gianluca Comerci
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Annalisa Pasquini
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Franco Cavaliere
- 60234 Catholic University of the Sacred Heart, Rome, Italy.,60234 Intensive Care Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Sergio Guarneri
- 60234 Intensive Care Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Emanuele Marzetti
- 60234 Catholic University of the Sacred Heart, Rome, Italy.,60234 Neurosciences and Orthopedics, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Alessia Rabini
- 60234 Physical Medicine and Rehabilitation Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Alessandra Piarulli
- Clinical Psychology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Valerio Sanesi
- 60234 Catholic University of the Sacred Heart, Rome, Italy
| | - Denise D'Errico
- Perfusion Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Massimo Massetti
- 60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,60234 Catholic University of the Sacred Heart, Rome, Italy
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26
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Abjigitova D, Veen KM, Mokhles MM, Bekkers JA, Oei FB, Bogers AJ. Initial clinical experience with minimally invasive surgical aortic valve replacement. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:268-277. [PMID: 33302611 DOI: 10.23736/s0021-9509.20.11463-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The ministernotomy approach is increasingly used in aortic valve surgery. However, the advantages are still a matter of discussion. The aim of this study was to compare the postoperative outcome in patients undergoing elective aortic valve operation, either through mini-sternotomy or conventional sternotomy. METHODS We included 317 patients who were treated for their aortic valve, 63 patients underwent a minimally invasive aortic valve replacement (mini-AVR) and 254 patients underwent a full-sternotomy AVR. Patients with endocarditis, those who underwent previous cardiac surgery and those who required a concomitant procedure were excluded from the analysis. The method of matching weights according to propensity score was used to adjust for differences between the two treatment groups, and outcomes were compared. RESULTS The mediastinal drainage was significantly lower at 6, 24 hours and total after mini-AVR procedure than after full-sternotomy AVR (median: 373 vs. 499 mL, P<0.001). However, the number of patients receiving packed red blood cells transfusion was similar. Overall, the hospital mortality was lower in the full-sternotomy group, 0% vs. 3.2%, P=0.039. No difference was found in the median hospital length of stay, perioperative myocardial infarction, postoperative incidence of new pacemaker implantation, stroke, prolonged mechanical ventilation and mediastinitis. No patients in the mini-AVR group experienced paravalvular leakage. Midterm survival resulted in no difference between the treatment groups at 4-year (90.5% vs. 95.2%), P=0.75. CONCLUSIONS Although the minimally invasive surgery for AVR may increasingly be applied, our initial experience calls for a careful approach of adapting this procedure.
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Affiliation(s)
- Djamila Abjigitova
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frans B Oei
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ad J Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands -
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27
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Meyer A, van Kampen A, Kiefer P, Sündermann S, Van Praet KM, Borger MA, Falk V, Kempfert J. Minithoracotomy versus full sternotomy for isolated aortic valve replacement: Propensity matched data from two centers. J Card Surg 2020; 36:97-104. [PMID: 33135258 DOI: 10.1111/jocs.15177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/22/2020] [Accepted: 08/31/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Minimally invasive approaches to isolated aortic valve replacement (AVR) continue to gain popularity. This study compares outcomes of AVR through right anterolateral thoracotomy (RALT) to those of AVR through full median sternotomy (MS). METHODS Outcomes of two propensity-matched groups of 85 each, out of 250 patients that underwent isolated AVR through RALT or MS at our two institutions, were compared in a retrospective study. RESULTS Propensity score matching resulted in 85 matched pairs with balanced preoperative characteristics. Procedure times were significantly shorter in the RALT group (median difference: 13 min [-25 to -0.5]; p = .039), cardiopulmonary bypass times were longer (median difference: 17 min [10-23.5]; p = < .001) and ventilation times shorter (median difference: 259 min [-390 to -122.5]; p = < .001). There was no significant difference in aortic cross-clamp times (median difference: 1.5 min [-3.5 to 6.5]; p = .573). The RALT group had lower rates of perioperative platelet transfusions (odds ratio [OR] = 0.00 [0.00-0.59]; p = .0078) and postoperative pneumonia (OR = 0.10 [0.00-0.70]; p = .012), as well as shorter hospitalization times (median difference: 2.5 days [-4.5 to -1]; p = .005). There were no significant differences regarding paravalvular leakage (p = .25), postoperative stroke (p = 1), postoperative atrial fibrillation (p = .12) or 1-year-mortality (p = 1). CONCLUSIONS This study found RALT to be an equally safe approach to surgical AVR as MS. Furthermore, RALT showed advantages regarding important aspects of postoperative recovery, especially concerning pulmonary function.
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Affiliation(s)
- Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Berlin Institute for Foundations of Learning and Data, Berlin, Germany
| | - Antonia van Kampen
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Philipp Kiefer
- University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Simon Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Michael A Borger
- University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
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28
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Ramsaransing K, Hindori V, Kougioumtzoglou A, Kaya A, Verbeek E. Minimally Invasive Sutureless Aortic Valve Replacement With the Perceval S Bioprosthesis Through Ministernotomy: A Single-Center Experience. Cureus 2020; 12:e11212. [PMID: 33269142 PMCID: PMC7707058 DOI: 10.7759/cureus.11212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives Minimally invasive aortic valve replacement has the potential advantage of faster postoperative recovery compared to open procedures. Moreover, aortic valve replacement with a sutureless valve shortens procedure time. The aim of this study is to report early postoperative outcomes and one-year survival of patients undergoing sutureless aortic valve replacement with the Perceval S bioprosthesis (LivaNova, Milan, Italy) through a ministernotomy. Methods A total of 110 patients underwent sutureless aortic valve replacement in our center with the Perceval S bioprosthesis through a ministernotomy between February 2016 and March 2019. Data regarding preoperative and operative details, hospital stay, postoperative outcomes within 30 days after surgery, and one-year mortality were assessed. Results The mean cross-clamping time and extracorporeal circulation time were 54 ± 14 and 78 ± 21 minutes, respectively. No conversion to full median sternotomy was needed perioperatively. In-hospital mortality was 0.9%. Postoperative peak gradient was 13.3 mmHg; no major paravalvular leakage or valve migration occurred postoperatively. Postoperative complications consisted of one (0.9%) patient requiring full sternotomy for bleeding and two (1.8%) patients requiring re-ministernotomy due to acute tamponade. Pacemaker implantation was needed in four (3.6%) patients. Postoperative ischemic stroke rate and new-onset atrial fibrillation were 0.9% (n = 1) and 20% (n = 22), respectively, and one-year survival was 97.3%. Median intensive care unit and hospital stay were one and eight day(s), respectively. Conclusion Minimally invasive sutureless aortic valve replacement with the Perceval S bioprosthesis through a ministernotomy appears to be a safe procedure with good postoperative results and one-year survival. Further follow-up is needed to evaluate long-term outcomes.
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Affiliation(s)
- Krishan Ramsaransing
- Cardiothoracic Surgery, Onze Lieve Vrouwe Gasthuis Ziekenhuis (OLVG) Amsterdam, Amsterdam, NLD
| | - Vikash Hindori
- Cardiothoracic Surgery, Onze Lieve Vrouwe Gasthuis Ziekenhuis (OLVG) Amsterdam, Amsterdam, NLD
| | | | - Abdullah Kaya
- Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, NLD
| | - Eva Verbeek
- Cardiothoracic Surgery, Onze Lieve Vrouwe Gasthuis Ziekenhuis (OLVG) Amsterdam, Amsterdam, NLD
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29
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Berretta P, Andreas M, Carrel TP, Solinas M, Teoh K, Fischlein T, Santarpino G, Folliguet T, Villa E, Meuris B, Mignosa C, Martinelli G, Misfeld M, Glauber M, Kappert U, Savini C, Shrestha M, Phan K, Albertini A, Yan T, Di Eusanio M. Minimally invasive aortic valve replacement with sutureless and rapid deployment valves: a report from an international registry (Sutureless and Rapid Deployment International Registry)†. Eur J Cardiothorac Surg 2020; 56:793-799. [PMID: 30820549 DOI: 10.1093/ejcts/ezz055] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/01/2019] [Accepted: 02/04/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The impact of sutureless and rapid deployment (SURD) valves on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. The aim of this study was to assess clinical characteristics and in-hospital results of patients receiving SURD-AVR through less invasive approaches in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS Of the 1935 patients who received primary isolated SURD-AVR between 2009 and 2018, a total of 1418 (73.3%) underwent MI interventions and were included in this analysis. SURD-AVR was performed using upper ministernotomy in 56.4% (n = 800) of cases and anterior right thoracotomy in 43.6% (n = 618). Perceval S was implanted in 1011 (71.3%) patients and Edwards Intuity or Intuity Elite in 407 (28.7%) patients. RESULTS Overall in-hospital mortality and stroke rates were 1.7% and 2%, respectively. A definitive pacemaker implantation was reported in 9% of cases and significantly decreased over the observational period, from 20.6% to 5.6% (P = 0.002). The Perceval valve was associated with shorter operative times and was more frequently implanted in patients receiving anterior right thoracotomy incision. The Intuity valve was preferred in younger patients and revealed superior postoperative haemodynamic results. CONCLUSIONS SURD-AVR was largely performed through less invasive approaches and can be considered as a primary indication in MI surgery. In the SURD-IR cohort, MI SURD-AVR using both Perceval and Intuity valves appeared a safe and reproducible procedure associated with promising early results.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Kevin Teoh
- Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Theodor Fischlein
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
| | | | | | | | - Bart Meuris
- Gasthuisberg, Cardiale Heelkunde, Leuven, Belgium
| | - Carmelo Mignosa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS-ISMETT, Palermo, Italy
| | | | | | - Mattia Glauber
- Istituto Clinico Sant'Ambrogio, Clinical & Research Hospitals IRCCS Gruppo San Donato, Milan, Italy
| | - Utz Kappert
- Dresden Heart Center, Department of Cardiac Surgery, Dresden University Hospital, Dresden, Germany
| | - Carlo Savini
- Cardiac Surgery Department, Sant'Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | | | | | - Tristan Yan
- The Collaborative Research (CORE) Group.,Macquarie University, Sydney, NSW, Australia
| | - Marco Di Eusanio
- The Collaborative Research (CORE) Group.,Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy
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D'Onofrio A, Tessari C, Lorenzoni G, Cibin G, Martinelli G, Alamanni F, Polvani G, Solinas M, Massetti M, Merlo M, Vendramin I, Di Eusanio M, Mignosa C, Mangino D, Russo C, Rinaldi M, Pacini D, Salvador L, Antona C, Maselli D, De Paulis R, Luzi G, Alfieri O, De Filippo CM, Portoghese M, Musumeci F, Colli A, Gregori D, Gerosa G. Minimally Invasive vs Conventional Aortic Valve Replacement With Rapid-Deployment Bioprostheses. Ann Thorac Surg 2020; 111:1916-1922. [PMID: 33039363 DOI: 10.1016/j.athoracsur.2020.06.150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/13/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this multicenter retrospective study was to compare early and midterm clinical and hemodynamic results of aortic valve replacement with rapid-deployment bioprostheses performed through conventional full-sternotomy vs mini-sternotomy. METHODS Data from the Italian multicenter registry of aortic valve replacement with rapid-deployment bioprostheses (INTU-ITA registry) were analyzed. Patients were divided into 2 groups: full sternotomy (FS) and ministernotomy (MS). Primary endpoint was the comparison of early and midterm mortality. Secondary endpoints were: comparison of intraoperative variables, complications, and hemodynamic performance. A propensity score weighting approach was used for data analysis. RESULTS A total of 1057 patients were analyzed: 435 (41.2%) and 622 (58.8%) in group FS and MS, respectively. Thirty-day mortality was 1.6% and 0.6% in FS and MS groups, respectively (P = .074). cardiopulmonary bypass time was 78.5 minutes and 83 minutes in FS and MS groups, respectively (P = .414). In the overall cohort, the incidence of intraoperative complications and of device success was 3.8% (40 patients) and 95.9% (1014 patients), respectively, with no significant differences between groups. Survival at 1, 3, and 5 years was 94.1%, 98.1%, 88.5% and 91.8%, 85.2%, and 84.8% in FS and MS groups, respectively (P = .412). The 2 groups showed similar postoperative gradients (median mean gradient, FS: 10.0 mm Hg, MS: 11.0 mm Hg; P = .170) and also similar incidence of patient-prosthesis mismatch (FS: 7%, MS: 6.4%, P = .647). CONCLUSIONS According to our data, rapid-deployment bioprostheses allow the performance of minimally invasive aortic valve replacement with similar surgical times and similar clinical and hemodynamic outcomes to conventional surgery and should be considered the first choice in these procedures.
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Affiliation(s)
- Augusto D'Onofrio
- Department of Cardiac Surgery, University Hospital of Padova, Padova, Italy.
| | - Chiara Tessari
- Department of Cardiac Surgery, University Hospital of Padova, Padova, Italy
| | - Giulia Lorenzoni
- Department of Cardiac Surgery, University Hospital of Padova, Padova, Italy
| | - Giorgia Cibin
- Department of Cardiac Surgery, University Hospital of Padova, Padova, Italy
| | | | - Francesco Alamanni
- Department of Cardiac Surgery, Centro Cardiologico Monzino, Milan, Italy
| | - Gianluca Polvani
- Department of Cardiac Surgery, Centro Cardiologico Monzino, Milan, Italy
| | - Marco Solinas
- Department of Cardiac Surgery, Ospedale del Cuore "G. Pasquinucci", Massa, Italy
| | - Massimo Massetti
- Department of Cardiac Surgery, Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Maurizio Merlo
- Department of Cardiac Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Igor Vendramin
- Department of Cardiac Surgery, S. Maria della Misericordia Hospital, University of Udine, Udine, Italy
| | | | - Carmelo Mignosa
- Department of Cardiac Surgery, G.B. Morgagni Hospital, Catania, Italy
| | - Domenico Mangino
- Department of Cardiac Surgery, L'Angelo Hospital, Mestre-Venezia, Italy
| | - Claudio Russo
- Department of Cardiac Surgery, Niguarda Hospital, Milan, Italy
| | - Mauro Rinaldi
- Department of Cardiac Surgery, University Hospital of Turin, Turin, Italy
| | - Davide Pacini
- Department of Cardiac Surgery, University Hospital of Bologna, Bologna, Italy
| | - Loris Salvador
- Department of Cardiac Surgery, San Bortolo Hospital, Vicenza, Italy
| | - Carlo Antona
- Department of Cardiac Surgery, Sacco Hospital, Milan, Italy
| | - Daniele Maselli
- Department of Cardiac Surgery, S. Anna Hospital, Catanzaro, Italy
| | | | - Giampaolo Luzi
- Department of Cardiac Surgery, San Carlo Hospital, Potenza, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, San Raffaele University Hospital, Milano, Italy
| | | | - Michele Portoghese
- Department of Cardiac Surgery, Santissima Annunziata Hospital, Sassari, Italy
| | | | - Andrea Colli
- Department of Cardiac Surgery, University Hospital of Pisa, Pisa, Italy
| | - Dario Gregori
- Department of Cardiac Surgery, University Hospital of Padova, Padova, Italy
| | - Gino Gerosa
- Department of Cardiac Surgery, University Hospital of Padova, Padova, Italy
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Woldendorp K, Doyle MP, Bannon PG, Misfeld M, Yan TD, Santarpino G, Berretta P, Di Eusanio M, Meuris B, Cerillo AG, Stefàno P, Marchionni N, Olive JK, Nguyen TC, Solinas M, Bianchi G. Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis. Ann Cardiothorac Surg 2020; 9:347-363. [PMID: 33102174 DOI: 10.21037/acs-2020-surd-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. Methods Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. Results Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. Conclusions Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.
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Affiliation(s)
- Kei Woldendorp
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mathew P Doyle
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Misfeld
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Tristan D Yan
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Adventist Hospital, Sydney, Australia
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.,Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany.,Department of Clinical and Experimental Medicine, Magna Graecia University, Catanzaro, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Pierluigi Stefàno
- Unit of Cardiac Surgery, Careggi University Hospital, Florence, Italy.,University of Florence School of Medicine, Florence, Italy
| | - Niccolò Marchionni
- University of Florence School of Medicine, Florence, Italy.,Unit of Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Heart and Vascular Institute, Houston, Texas, USA
| | - Marco Solinas
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
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Shneider YA, Tsoi MD, Fomenko MS, Pavlov AA, Shilenko PA. [Aortic valve replacement via J-shaped partial upper sternotomy: randomized trial, mid-term results]. Khirurgiia (Mosk) 2020:25-30. [PMID: 32736460 DOI: 10.17116/hirurgia202007125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of aortic valve replacement through upper partial J-shaped sternotomy compared to conventional sternotomy. MATERIAL AND METHODS There were 240 procedures of isolated aortic valve replacement for the period 2012-2017. According to inclusion criteria, 112 patients were randomized into 2 groups: group I - median sternotomy, group II - upper partial J-shaped sternotomy. Mean age of patients was 56.1±14.3 and 53.1±14.9 years, respectively (p=0.284). Females prevailed in both groups (55.4% vs. 57.1%, p=0.848). Peak pressure gradient on the aortic valve was 106.2±23.9 and 102.8±25.3 mm Hg, respectively (p=0.484). RESULTS In-hospital mortality was 1.8% (n=1) in group I (p=0.315). Incidence of postoperative complications (complete atrioventricular blockade, ventricular septal defect) was similar (p=1.0). Mean time cross clamping in I and II groups was 65.5±12.5 and 64.7±13.1 min (p=0.729). Mean follow-up period was 31.6 and 33.5 months, respectively. Kaplan-Meier survival rate was 92.6 and 93.0%, respectively (log-rank test=0,767). Freedom from thromboembolic events was 91.7 and 90% (log-rank test=0.213). CONCLUSION. U Pper partial J-shaped sternotomy is safe and effective for aortic valve surgery and characterized by similar outcomes compared to conventional sternotomy.
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Affiliation(s)
- Yu A Shneider
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - M D Tsoi
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - M S Fomenko
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - A A Pavlov
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - P A Shilenko
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
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Kenawy A, Abdelbar A, Tennyson C, Taylor R, Zacharias J. Is it safe to move away from a full sternotomy for aortic valve replacement? Asian Cardiovasc Thorac Ann 2020; 28:553-559. [PMID: 32727206 DOI: 10.1177/0218492320948321] [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: 11/17/2022]
Abstract
BACKGROUND Minimally invasive surgical approaches have gained popularity among patients and surgeons. The aim of this project was to assess the safety of initiating aortic valve replacement via an anterior right thoracotomy program. METHODS Between May 2015 and May 2019, data of all isolated primary aortic valve replacements were extracted retrospectively from our prospectively collected database and categorized into conventional median sternotomy, hemisternotomy, and anterior right thoracotomy cases. In total, 661 patients underwent isolated primary aortic valve replacement, of whom 429 (65%) had a median sternotomy, 126 (19%) had a hemisternotomy, and 106 (16%) had an anterior right thoracotomy. Preoperative characteristics were similar in each of the three groups. Statistical testing of the surgical groups was undertaken using the chi-square test for categorical variables and one-way analysis of variance with Tukey post-hoc pairwise tests (where appropriate) for continuous variables, to identify differences between pairs of data. RESULTS Cardiopulmonary bypass and crossclamp times were significantly longer in the anterior right thoracotomy group compared to the hemisternotomy and median sternotomy groups (p < 0.001). Blood loss was significantly less and hospital stay significantly shorter in the hemisternotomy group compared to median sternotomy group but not the anterior right thoracotomy group. Mortality, stroke, renal, gastrointestinal and respiratory complications showed no statistical differences. CONCLUSION Surgical aortic valve replacement had a very low mortality and morbidity in our experience, and it is safe to start a minimal access program for aortic valve replacement.
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Affiliation(s)
- Ayman Kenawy
- Department of Cardiothoracic surgery, Blackpool Victoria Hospital, Blackpool, UK
| | - Abdelrahman Abdelbar
- Department of Cardiothoracic surgery, Blackpool Victoria Hospital, Blackpool, UK
| | - Charlene Tennyson
- Department of Cardiothoracic surgery, Blackpool Victoria Hospital, Blackpool, UK
| | - Rebecca Taylor
- Clinical Research Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Joseph Zacharias
- Department of Cardiothoracic surgery, Blackpool Victoria Hospital, Blackpool, UK
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Yousuf Salmasi M, Hamilton H, Rahman I, Chien L, Rival P, Benedetto U, Young C, Caputo M, Angelini GD, Vohra HA. Mini‐sternotomy vs right anterior thoracotomy for aortic valve replacement. J Card Surg 2020; 35:1570-1582. [DOI: 10.1111/jocs.14607] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | - Lueh Chien
- Department of Surgery Imperial College London London UK
| | - Paul Rival
- Department of Cardiac Surgery Bristol Heart Institute Bristol UK
| | | | | | - Massimo Caputo
- Department of Cardiac Surgery Bristol Heart Institute Bristol UK
| | | | - Hunaid A. Vohra
- Department of Cardiac Surgery Bristol Heart Institute Bristol UK
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Di Eusanio M, Berretta P. The sutureless and rapid-deployment aortic valve replacement international registry: lessons learned from more than 4,500 patients. Ann Cardiothorac Surg 2020; 9:289-297. [PMID: 32832410 PMCID: PMC7415696 DOI: 10.21037/acs-2020-surd-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/28/2020] [Indexed: 01/04/2023]
Abstract
The treatment options for patients with aortic valve disease have considerably expanded over the last decade. The remarkable advances in catheter-based technology, the popularizing of minimally invasive (MI) surgery, and the introduction of new valve technologies, such as sutureless and rapid-deployment (SURD) valves have led to a paradigm shift in the management of aortic valve pathologies. Yet, given their recent introduction, the current evidence on sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has been limited thus far. The Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR) was established in 2015 by a consortium of 18 research centers to assess safety, efficacy, short- and long-term outcomes of SURD-AVR interventions. The present keynote lecture aims to assess and comment on the real-world evidence for SURD-AVR surgery generated from the SURD-IR.
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Affiliation(s)
- Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Solinas M, Bianchi G, Chiaramonti F, Margaryan R, Kallushi E, Gasbarri T, Santarelli F, Murzi M, Farneti P, Leone A, Simeoni S, Varone E, Marchi F, Glauber M, Concistrè G. Right anterior mini-thoracotomy and sutureless valves: the perfect marriage. Ann Cardiothorac Surg 2020; 9:305-313. [PMID: 32832412 DOI: 10.21037/acs-2019-surd-172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background A minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates a MIA. We describe our experience with the sutureless Perceval (LivaNova, Italy) aortic bioprosthesis through a right anterior mini-thoracotomy (RAMT) approach. Methods Between March 2011 and October 2019, 1,049 patients underwent AVR with Perceval bioprosthesis. Five hundred and three patients (48%) were operated through a RAMT approach in the second intercostal space. Considering only isolated AVR (881), 98% of patients were operated with MIA, and Perceval in RAMT approach was performed in 57% of these patients. Eight patients (1.6%) had previously undergone cardiac surgery. The prosthesis sizes implanted were: S (n=91), M (n=154), L (n=218) and XL (n=40). Concomitant procedures were mitral valve surgery (n=6), tricuspid valve repair (n=1), mitral valve repair and tricuspid valve repair (n=1) and miectomy (n=2). Mean age was 78±4 years (range, 65-89 years), 317 patients were female (63%) and EuroSCORE II was 5.9%±8.4%. Results The 30-day mortality was 0.8% (4/503). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were 81.6±30.8 and 50.3±24.5 minutes respectively for stand-alone procedures. In two patients, early moderate paravalvular leakage appeared as a result of incomplete expansion of the sutureless valve due to oversizing of the bioprosthesis, requiring reoperations at two and nine postoperative days with sutured aortic bioprosthesis implantation. Permanent pacemaker implantation within the first thirty days was necessary in 26 (5.2%) patients. At the mean follow-up of 4.6 years (range, 1 month to 8.6 years), survival was 96%, freedom from reoperation was 99.2%, and mean transvalvular pressure gradient was 11.9±4.3 mmHg. Conclusions AVR with the Perceval bioprosthesis in a RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates a RAMT approach.
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Affiliation(s)
- Marco Solinas
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Giacomo Bianchi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Francesca Chiaramonti
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Rafik Margaryan
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Enkel Kallushi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Tommaso Gasbarri
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Filippo Santarelli
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Michele Murzi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Pierandrea Farneti
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Alessandro Leone
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Simone Simeoni
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Egidio Varone
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Federica Marchi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Mattia Glauber
- Department of Minimally-Invasive Cardiac Surgery, Istituto Clinico Sant' Ambrogio, Milan, Italy
| | - Giovanni Concistrè
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
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Elghannam M, Aljabery Y, Naraghi H, Moustafine V, Bechte M, Strauch J, Haldenwang P. Minimally invasive aortic root surgery: Midterm results in a 2-year follow-up. J Card Surg 2020; 35:1484-1491. [PMID: 32445199 DOI: 10.1111/jocs.14628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Minimally invasive surgery (MIS) via partial upper sternotomy (PUS) for aortic root surgery represents an alternative to the full median sternotomy (FMS). PUS offers less operative trauma. We analyzed the midterm outcome of root replacement (Bentall) or valve-sparing root replacement (David) via PUS to evaluate the safety of this access. METHODS Between November 2011 to April 2017, a total of 47 consecutive patients underwent aortic root surgery with aortic aneurysm and/or localized aortic dissection through Bentall or David operation through PUS mean age (57.9 ± 10.5 years). Bentall operation was performed in 36 patients (77%), whereas 11 patients (23%) received a David procedure. The outcome was carried out in 6-months, 1-year, and 2-years-follow up. RESULTS Mean operation time was 287.3 ± 72.6 minutes, mean cardiopulmonary bypass (CPB) time 174 ± 54.8 minutes, mean cross-clamp time 133 ± 33.1 minutes. Rethoracotomy-rate was (4.2%). Superficial wound healing disturbance was (2%) and no deep sternal infection or sternum instability occurred. Hospitalization-and intensive care unit-stay was 11.8 ± 4.4 and 1.9 ± 1.3 days with a total median ventilation-time of 10 (IQR 7.5-13.5) hours. There was no 30-day-mortality. After 2 years the total rate of mortality, major adverse cardiac and cerebrovascular events, and redo surgery was (6.3%, 4.2%, and 4.2%). CONCLUSIONS Minimally invasive aortic root surgery via partial upper sternotomy could be a safe alternative to the full median sternotomy. It requires longer operative times but reduces postoperative morbidity with good postoperative outcome.
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Affiliation(s)
- Mahmoud Elghannam
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Yazan Aljabery
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Hamid Naraghi
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Vadim Moustafine
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Matthias Bechte
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Justus Strauch
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Peter Haldenwang
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
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Mohammed H, Yousuf Salmasi M, Caputo M, Angelini GD, Vohra HA. Comparison of outcomes between minimally invasive and median sternotomy for double and triple valve surgery: A meta-analysis. J Card Surg 2020; 35:1209-1219. [PMID: 32306504 DOI: 10.1111/jocs.14558] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to median sternotomy (MS) for multiple valvular disease (MVD). This systematic review and meta-analysis aims to compare operative and peri-operative outcomes of MIS vs MS in MVD. METHODS PubMed, Ovid, and Embase were searched from inception until August 2019 for randomized and observational studies comparing MIS and MS in patients with MVD. Clinical outcomes of intra- and postoperative times, reoperation for bleeding and surgical site infection were evaluated. RESULTS Five observational studies comparing 340 MIS vs 414 MS patients were eligible for qualitative and quantitative review. The quality of evidence assessed using the Newcastle-Ottawa scale was good for all included studies. Meta-analysis demonstrated increased cardiopulmonary bypass time for MIS patients (weighted mean difference [WMD], 0.487; 95% confidence interval [CI], 0.365-0.608; P < .0001). Similarly, aortic cross-clamp time was longer in patients undergoing MIS (WMD, 0.632; 95% CI, 0.509-0.755; P < .0001). No differences were found in operative mortality, reoperation for bleeding, surgical site infection, or hospital stay. CONCLUSIONS MIS for MVD have similar short-term outcomes compared to MS. This adds value to the use of minimally invasive methods for multivalvular surgery, despite conferring longer operative times. However, the paucity in literature and learning curve associated with MIS warrants further evidence, ideally randomized control trials, to support these findings.
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Affiliation(s)
- Haya Mohammed
- Faculty of Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Massimo Caputo
- Department of Cardiovascular Sciences, Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiovascular Sciences, Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | - Hunaid A Vohra
- Department of Cardiovascular Sciences, Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
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Maimari M, Baikoussis NG, Gaitanakis S, Dalipi-Triantafillou A, Katsaros A, Kantsos C, Lozos V, Triantafillou K. Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation? Ann Card Anaesth 2020; 23:7-13. [PMID: 31929240 PMCID: PMC7034196 DOI: 10.4103/aca.aca_158_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Atrial fibrillation (AF) is the most common post-operative complication and tends to be the most common arrhythmia after cardiac surgery. The etiology and risk factors for post-operative AF are poorly understood, but older age, large left atrium, diffuse coronary artery disease, a history of AF paroxysms and in general, pre-existing cardiac conditions that cause restricting and susceptibility towards inflammation have been consistently linked with post-operative atrial fibrillation (POAF). It has been traditionally thought that post-operative AF is transient, well-tolerated, benign to the patient and self-limiting complication of cardiac surgery that was temporary and easily treated. However, recent evidence suggests that POAF may be more "malignant" than previously thought, associated with follow-up mortality and morbidity. Several minimally invasive approaches, including the right parasternal approach, upper and lower mini-sternotomy (MS), V-shaped, Z-shaped, inverse-T, J-, reverse-C and reverse-L partial MS, transverse sternotomy and right mini-thoracotomy, have been developed for cardiac surgery operations since 1993 and have been associated with better outcomes and lower perioperative morbidity compared to full sternotomy (FS). The common goal of several minimally invasive approaches is to reduce invasiveness and surgical trauma. According to a statement from the American Heart Association (AHA), the term "minimally invasive" refers to a small chest wall incision that does not include a FS. This review is aimed to evaluate the use of minimally invasive techniques like mini-sternotomy, mini-thoracotomy and hybrid techniques versus conventional techniques which are used in cardiac surgery and to compare the frequency of post-operative AF and its effect on post-operative complications, morbidity and mortality, after cardiac surgery operations with FS versus cardiac surgery operations with the use of minimally invasive techniques.
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Affiliation(s)
- Maria Maimari
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Nikolaos G Baikoussis
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Stelios Gaitanakis
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | | | - Andreas Katsaros
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Charilaos Kantsos
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Vasileios Lozos
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
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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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Concistrè G, Bianchi G, Chiaramonti F, Margaryan R, Marchi F, Kallushi E, Solinas M. Minimally Invasive Sutureless Aortic Valve Replacement is Associated With Improved Outcomes in Patients With Left Ventricular Dysfunction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:445-452. [DOI: 10.1177/1556984519872990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis compared with patients with preserved LVEF. To evaluate the impact of sutureless Perceval (LivaNova, Italy) aortic bioprosthesis on LVEF and clinical outcomes in patients with baseline left ventricular (LV) dysfunction who underwent isolated aortic valve replacement (AVR). Methods Between March 2011 and August 2017, 803 patients underwent AVR with Perceval bioprosthesis implantation. Fifty-two isolated AVR had preoperative LVEF ≤45%. Mean age of these patients was 77 ± 6 years, 24 patients were female (46%), and mean EuroSCORE II was 9.4% ± 4.8%. Perceval bioprosthesis was implanted in 9 REDO operations. In 43 patients (83%), AVR was performed in minimally invasive surgery with an upper ministernotomy ( n = 13) or right anterior minithoracotomy ( n = 30). Results One patient died in hospital. Cardiopulmonary bypass and aortic cross-clamp times were 85.5 ± 26 minutes and 55.5 ± 19 minutes, respectively. At mean follow-up of 33 ± 20 months (range: 1 to 75 months), survival was 90%, freedom from reoperation was 100%, and mean transvalvular pressure gradient was 11 ± 5 mmHg. LVEF improved from 37% ± 7% preoperatively to 43% ± 8% at discharge ( P < 0.01) and further increased to 47% ± 9% at follow-up ( P = 0.06), LV mass decreased from 149.8 ± 16.9 g/m2 preoperatively to 115.3 ± 11.6 g/m2 at follow-up ( P < 0.001), and moderate paravalvular leakage occurred in 1 patient without hemolysis not requiring any treatment. Conclusions AVR with sutureless aortic bioprosthesis implantation in patients with preoperative LV dysfunction demonstrated a significant immediate and early improvement in LVEF.
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Affiliation(s)
- Giovanni Concistrè
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Giacomo Bianchi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Francesca Chiaramonti
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Rafik Margaryan
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Federica Marchi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Enkel Kallushi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Marco Solinas
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
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Bruno P, Cammertoni F, Rosenhek R, Mazza A, Pavone N, Iafrancesco M, Nesta M, Chiariello GA, Spalletta C, Graziano G, Sanesi V, D’Errico D, Massetti M. Improved Patient Recovery With Minimally Invasive Aortic Valve Surgery: A Propensity-Matched Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:419-427. [DOI: 10.1177/1556984519868715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Despite conflicting evidence available, minimally invasive aortic valve replacement (MIAVR) is increasingly used as an alternative to full sternotomy. We sought to compare early outcomes of aortic valve replacement through a full sternotomy (conventional aortic valve replacement [CAVR]) and upper ministernotomy (MIAVR). Methods We analyzed 297 patients having undergone primary, elective, isolated MIAVR or CAVR between January 2014 and June 2018. Following propensity score matching, 120 patients remained in each group. Results MIAVR required longer bypass (93 ± 26 vs 81 ± 24 minutes, P < 0.01) and operative times (214 ± 39 vs 182 ± 37 minutes, P < 0.01). However, aortic cross-clamp times were comparable (57 ± 17 vs 54 ± 14 minutes for MIAVR and CAVR, respectively, P = 0.14). MIAVR had less 24-hour blood loss (253 ± 204 vs 323 ± 296 mL, P = 0.03), less red blood cells transfusions [1.4 packs (1.1 o 1.9) vs 2.1 packs (1.8 to 2.7), P = 0.01], and shorter assisted ventilation time (7.1 ± 3.3 vs 9.7 ± 3.8 hours, P < 0.01) when compared to CAVR. These results led to significantly shorter intensive care unit and hospital stays for MIAVR patients (2.5 ± 1.3 vs 3.4 ± 1.1 days, P < 0.01 and 6.9 ± 4.1 vs 8.2 ± 4.8 days, P = 0.03, respectively). Thirty-day mortality and clinical outcomes did not differ significantly among groups. Conclusions MIAVR through upper ministernotomy was shown to be as safe and reliable as CAVR. Patient recovery time was improved by shortening mechanical ventilation and reducing blood loss and transfusions. These results may be significant for high-risk patients undergoing aortic valve surgery.
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Affiliation(s)
- Piergiorgio Bruno
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Raphael Rosenhek
- Department of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Andrea Mazza
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Natalia Pavone
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Mauro Iafrancesco
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | | | | | | | | | - Denise D’Errico
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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Jahangiri M, Hussain A, Akowuah E. Minimally invasive surgical aortic valve replacement. Heart 2019; 105:s10-s15. [DOI: 10.1136/heartjnl-2018-313512] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/12/2018] [Accepted: 10/16/2018] [Indexed: 11/03/2022] Open
Abstract
Minimally invasive aortic valve replacement (MIAVR) is defined as a surgical aortic valve replacement which involves smaller chest incisions as opposed to full sternotomy. It is performed using cardiopulmonary bypass with cardiac arrest. It benefits from potential advantages of a less invasive procedure. To date, over 14 000 MIAVR have been reported in the literature. Due to heterogeneity of the studies, different surgical techniques and mainly the non-randomised nature of these studies comparing MIAVR with conventional aortic valve replacement, it is difficult to draw definitive conclusions. The two main techniques of MIAVR are mini-sternotomy and right anterior mini-thoracotomy. Both techniques with other less common forms of MIAVR will be discussed in this review. The advantages, disadvantages and surgical pitfalls will be discussed. Some of the advantages include shorter intensive care and hospital stay, reduced perioperative blood loss, less pain, improved respiratory function and cosmesis. The possible disadvantage of longer bypass and cross-clamp times may be counter balanced by the recent sutureless and rapid deployment valves. Despite some of the benefits, MIAVR has not been adopted by a significant proportion of the surgeons possibly related to the learning curve and requirements for re-training. As MIAVR becomes more common, randomised trials comparing this technique with transcatheter aortic valve implantation is warranted. In addition, assessing quality of life including return to work and functional capacity is needed.
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Reemplazo valvular aórtico con bioprótesis sin sutura Perceval S: experiencia de un solo centro. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2019.01.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Minimally Invasive Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: Propensity Matched Initial Experience. Heart Lung Circ 2019; 28:320-326. [DOI: 10.1016/j.hlc.2017.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 11/18/2022]
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Young CP, Sinha S, Vohra HA. Outcomes of minimally invasive aortic valve replacement surgery. Eur J Cardiothorac Surg 2019; 53:ii19-ii23. [PMID: 29718235 DOI: 10.1093/ejcts/ezy186] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/06/2018] [Indexed: 11/13/2022] Open
Abstract
Minimally invasive aortic valve replacement has been used for more than 20 years, but its uptake has been limited. The volumes have increased steadily over the last 10 years, but it is still not regarded as a mainstream procedure. The issue, to some extent, is due to the lack of perceived evidence that minimal access incisions confer any benefit other than cosmetic appearance. In this article, the current literature on minimally invasive aortic valve replacement is reviewed, and it is concluded that benefits are demonstrable, particularly in higher risk, comorbid settings.
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Affiliation(s)
| | - Shubhra Sinha
- The Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
| | - Hunaid A Vohra
- The Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
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Nešpor D, Ondrášek J, Štěrba J, Kára T, Němec P. Our experience with surgical minimally invasive aortic valve replacement. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference? Ann Thorac Surg 2018; 106:1782-1788. [PMID: 30179623 DOI: 10.1016/j.athoracsur.2018.07.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/29/2018] [Accepted: 07/06/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study compared perioperative results and mortality rates of different approaches to perform aortic valve replacement (AVR), describing predictors favoring one approach over the others. METHODS All patients who underwent AVR were enrolled. The choice of the approach was left to surgeon's preference. Data were retrospectively collected, and the major baseline characteristics (including age, sex, body mass index, creatinine clearance, preoperative condition, cardiovascular risk factors, functional status, and left ventricular ejection fraction, etc.) and intraoperative variables were recorded. To adjust for differences in baseline characteristics between the study groups, a propensity score matching was performed. Linear and logistic regression analyses were performed. RESULTS Partial upper hemisternotomy was performed in 820 patients (43%), right anterior minithoracotomy in 488 (26%), and median sternotomy in 599 (31%). After propensity score matching, three groups of 377 patients were obtained. Cardiopulmonary bypass and cross-clamp times were shorter in the right anterior minithoracotomy group than in the median sternotomy and partial upper hemisternotomy groups (p < 0.001). No significant differences in in-hospital mortality were observed (p = 0.9). Renal failure (odds ratio, 5.4; 95% confidence interval, 2.3 to 11.4; p < 0.0001), extracardiac arteriopathy (odds ratio, 2.9; 95% confidence interval, 1.1 to 6.7; p = 0.017), and left ventricular ejection fraction (odds ratio, 0.96; 95% confidence interval, 0.93 to 0.99; p = 0.009) emerged as independent predictors of in-hospital mortality. CONCLUSIONS Minimal-access isolated aortic valve surgery is a reproducible, safe, and effective procedure with similar outcomes and operating times compared with conventional sternotomy.
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Abstract
PURPOSE OF REVIEW Sutureless aortic valve replacement (AVR) has emerged as an alternative to traditional AVR for patients with aortic stenosis who present a higher surgical risk, such as the elderly, or those with small or highly calcified aortic roots. With transcatheter aortic valve implantation - the other major AVR alternative - being used in increasingly lower-risk patients, the place of sutureless valves in the AVR landscape needs to be defined. In this review, we discuss recent data and expert opinion as it pertains to the subject of sutureless AVR. RECENT FINDINGS Several recent studies have evaluated the performance of sutureless valves in a variety of clinical contexts, including minimally invasive operations and high-risk surgical procedures. The optimal surgical technique for sutureless AVR has been refined through the publication of several reports addressing technical considerations. Reduction in operative times represents the main advantage of sutureless valves over conventional surgical prostheses, and the possibility of complete annular decalcification - and hence a reduced incidence of paravalvular leak - is the primary advantage over TAVI. SUMMARY Sutureless valves have emerged as an attractive option for high-risk patients or for complex surgeries where a minimization of bypass time is critical. However, there is limited data regarding long-term outcomes, durability or reoperation.
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Chauvette V, Mazine A, Bouchard D. Ten-year experience with the Perceval S sutureless prosthesis: lessons learned and future perspectives. J Vis Surg 2018; 4:87. [PMID: 29963376 DOI: 10.21037/jovs.2018.03.10] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 02/03/2018] [Indexed: 12/26/2022]
Abstract
Aortic stenosis has traditionally been addressed with surgical aortic valve replacement (AVR). In recent years, several technologies have emerged as alternative treatment methods for aortic valve disease. Among them, the Perceval (LivaNova, London, UK) is a sutureless valve that has been used in clinical practice for over 10 years. It has been implanted in over 20,000 patients worldwide. With nearly 600 Perceval implants since 2011, the Montreal Heart Institute has developed a worldwide expertise with this technology. In this article, we provide an overview of the clinical data currently available in the literature and discuss the lessons we have learned from our experience with the Perceval prosthesis.
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Affiliation(s)
- Vincent Chauvette
- Division of Cardiac Surgery, University of Montreal, Montreal, QC, Canada
| | - Amine Mazine
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
| | - Denis Bouchard
- Division of Cardiac Surgery, Montreal Heart Institute, Montreal, QC, Canada
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