Right Minithoracotomy for Mitral Valve Surgery: Impact of Tailored Strategies on Early Outcome

Minimally Invasive Mitral Valve Surgery in Elderly Patients: Results from a Multicenter Study

Background: Minimally invasive mitral valve surgery (MIMVS) has been increasingly adopted worldwide as an alternative to conventional sternotomy, especially for young patients. The remarkable results gained by MIMVS have encouraged its application in more complex and fragile patients, such as the elderly, though results in this subgroup remain controversial. It is the aim of this study to assess the postoperative outcomes of patients older than 75 years old undergoing MIMVS, and to compare these results to those of younger patients. Methods: The data of all patients undergoing MIMVS between 2015 and 2022 were retrospectively collected at seven high-volume cardiac surgery centers. Patients were divided into two age-based groups: the young (<65 years old) and the elderly (>75 years old). A propensity score (PS) matching analysis obtained two comparable groups. Postoperative outcomes were assessed in both the unmatched and PS-matched populations. Results: Out of 1113 patients undergoing MIMVS, 524 were young and 279 were elderly. Elderly patients were more commonly affected by multiple comorbidities, with a higher EuroSCORE II (4.6 ± 5.5% vs. 1.6 ± 3.3%, p < 0.001). There was no difference in postoperative mortality, though the elderly had a greater incidence of postoperative complications, such as re-exploration for bleeding, stroke, reintubation, and a need for hemodialysis and blood transfusions. After PS matching, 119 pairs of young and elderly patients with similar risk profiles (EuroSCORE II 2.5 ± 4.7% vs. 2.7 ± 3.2%, p = 0.7) were compared, and no differences in all postoperative outcomes were found. Conclusions: Adequately selected elderly patients can report hospital outcomes similar to young patients after MIMVS.

Clinical Impact of the Endo-aortic Clamp for Redo Mitral Valve Surgery

Aim of this study was to compare redo MV surgery patients undergoing right mini-thoracotomy and EAC with redo MV patients undergoing surgery through other approaches. Redo MV patients from 7 European centers were analyzed. Primary endpoint was 30-day mortality; secondary endpoints were stroke, re-exploration, low cardiac output syndrome (LCOS), respiratory failure, and intensive care unit (ICU) and in-hospital length-of-stay. Forty-nine patients underwent right mini-thoracotomy and EAC (22.7%), and 167 (77.3%) underwent surgery through other approaches (112 sternotomy, 40 unclamped mini-thoracotomies, and 15 mini-thoracotomies with trans-thoracic clamp). Thirty-day mortality, stroke, re-exploration for bleeding, and weaning failure were comparable. The EAC group showed significant lower rate of LCOS (p = 0.03) and shorter ICU (p = 0.04) and in-hospital length of stay (p = 0.002). The EAC allows the surgeon to reach the aorta, to clamp it, and to deliver the cardioplegia with a "no-touch" technique, with significant improvement in outcomes.

Transthoracic Cross Clamp versus Endoaortic Balloon Occlusion in Minimally Invasive Mitral Valve Surgery: A Pooled Study with Subgroup Analyses

Objective: We assessed the available literature regarding patients undergoing minimally invasive mitral valve surgery (MIMVS) with either transthoracic clamping (TTC) or endoaortic balloon occlusion (EABO). Methods: Original research studies that evaluated the perioperative outcomes of TTC versus EABO group were identified from 2000 to 2024. The incidence of all-cause mortality, cerebrovascular accidents (CVA), and aortic dissections were the primary endpoints. The cardiopulmonary bypass (CPB), cross-clamp, and ventilation time, along with the incidence of conversion to sternotomy, re-exploration, new-onset atrial fibrillation (AF), postoperative acute kidney injury (AKI), ICU stay, and LOS were the secondary endpoints. Subgroup analyses were performed regarding the EABO cannulation approach (femoral and aortic) and MIMVS approach (video-assisted and robotic-assisted). Sensitivity analyses were performed with the leave-one-out method and by including risk-adjusted populations. Results: Sixteen studies were included in both the qualitative and quantitative syntheses. After pooling data from 6335 patients, both groups demonstrated similar outcomes on all primary and secondary endpoints in the non-adjusted and adjusted total cohort analyses. These outcomes were further validated by the leave-one-out sensitivity analysis. In addition, the aortic cannulation EABO was associated with a lower cross-clamp time, followed by TTC and the femoral cannulation EABO approach. Furthermore, in the video-assisted subgroup analysis, the EABO approach was associated with a higher incidence of CVA, conversion to sternotomy, and longer ICU stay compared to the TTC group. Conclusions: The present meta-analysis indicates that both aortic occlusion techniques are safe and feasible in the context of MIMVS. A future well-designed randomized-control trial should further validate the current outcomes.

Surgical Treatment for Isolated Tricuspid Valve Disease: A Less Invasive Approach for Better Outcomes

Background. Severe tricuspid valve (TV) disease has a strong association with right ventricle dysfunction, heart failure and mortality. Nevertheless, surgical indications for isolated TV disease are still uncommon. The purpose of this study is to analyze outcomes of patients undergoing minimally invasive isolated TV surgery (ITVS). Methods. Data of patients undergoing right mini-thoracotomy ITVS were prospectively collected. A subgroup analysis was performed on late referral patients. Five-year survival was assessed using the Kaplan-Meier survival estimate. Results. Eighty-one consecutive patients were enrolled; late referral was recorded in 8 out of 81 (9.9%). No cases of major vascular complications nor of stroke were reported. A 30-day mortality was reported in one patient (1.2%). Five-year Kaplan-Meier survival analysis revealed a significant difference between late referral patients and the control group (p = 0.01); late referral and Euroscore II were found to be significantly associated with reduced mid-term survival (p = 0.005 and p = 0.01, respectively). Conclusions. To date, perioperative mortality in patients undergoing ITVS is still consistently high, even in high-volume, high-experienced centres, and this accounts for the low rate of referral. Results from our report show that, with proper multidisciplinary management, appropriate pre-operative screening, and allocation to the safest approach, ITVS may offer better results than expected.

The frail patient undergoing cardiac surgery: lessons learned and future perspectives

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

Single-Dose St. Thomas Versus Custodiol® Cardioplegia for Right Mini-thoracotomy Mitral Valve Surgery

OBJECTIVE

Custodiol® and St. Thomas cardioplegia are widely employed in mini-thoracotomy mitral valve (MV) operations. One-dose of the former provides 3 h of myocardial protection. Conversely, St. Thomas solution is usually reinfused every 30 min and safety of single delivery is unknown. We aimed to compare single-shot St. Thomas versus Custodiol® cardioplegia.

METHODS

Primary endpoint of the prospective observational study was cardiac troponin T level at different post-operative time-points. Propensity-weighted treatment served to adjust for confounding factors.

RESULTS

Thirty-nine patients receiving St. Thomas were compared with 25 patients receiving Custodiol® cardioplegia; cross-clamping always exceeded 45 min. No differences were found in postoperative markers of myocardial injury. Ventricular fibrillation at the resumption of electric activity was more frequent following Custodiol® cardioplegia (P = .01).

CONCLUSION

Effective myocardial protection exceeding 1 h of ischemic arrest can be achieved with a single-dose St. Thomas cardioplegia in selected patients undergoing right mini-thoracotomy MV surgery.

Minimally Invasive Beating Heart Mitral Valve Repair in a Patient With Connective Tissue Disease at Prohibitive Risk for Redo Sternotomy

Sternal reentry when the ascending aorta is adherent to the posterior table of the sternum is associated with substantial risk. A minimally invasive right thoracotomy beating heart approach is an alternative when the aorta cannot be cross-clamped. This report details this technique for a complex reoperative mitral valve repair procedure performed in a patient with connective tissue disease who had required multiple aortic operations and presented with heart failure and severe functional mitral regurgitation.

Minimally Invasive Valvular Surgery in the Elderly - Safety, Early Recovery, and Long-Term Outcomes

BACKGROUND

For elderly people, the benefit of minimally invasive cardiac surgery (MICS) is unclear, so we evaluated the safety, recovery, and long-term survival in elderly MICS patients.

METHODS AND RESULTS

63 propensity score-matched pairs of 213 consecutive patients (≥70 years old) who underwent mitral and/or tricuspid valve surgery between 2010 and 2020 (121 right mini-thoracotomies vs. 92 full sternotomies) were compared. The primary outcome was safety (composite endpoint of in-hospital death or major complication). Secondary outcomes were early ambulation and discharge to home. There were no differences between the groups for in-hospital death (3.2% vs. 0.0%, P=0.157) and primary outcome (14.3% vs. 17.5%, P=0.617). The rate of early ambulation (73.0% vs. 55.6%, P=0.048) and discharge to home (66.7% vs. 49.2%, P=0.034) were significantly higher in the mini-thoracotomy group. Major complication was an independent negative predictor of early ambulation for mini-thoracotomy but not for a conservative approach. Survival was 87.8±4.4% vs. 86.8±4.7% at 5 years, which was not significantly different.

CONCLUSIONS

Similar safety but better recovery were observed for mini-thoracotomy, and long-term survival was comparable between groups. Major complication was a negative predictor of early ambulation after mini-thoracotomy. Careful preoperative risk stratification would enhance the benefits of MICS in elderly patients.

Decision Making during the Learning Curve of Minimally Invasive Mitral Valve Surgery: A Focused Review for the Starting Minimally Invasive Surgeon

Minimally invasive mitral valve surgery is evolving rapidly since the early 1990’s and is now increasingly adopted as the standard approach for mitral valve surgery. It has a long and challenging learning curve and there are many considerations regarding technique, planning and patient selection when starting a minimally invasive program. In the current review, we provide an overview of all considerations and the decision-making process during the learning curve.

Chronic postsurgical pain and quality of life after right minithoracotomy mitral valve operations

OBJECTIVES

Chronic postsurgical pain (CPSP) is a relatively common complication after cardio-thoracic operations with well-known consequences in terms of return to normal activities and quality of life. Little is known about the prevalence and severity of CPSP after minimally invasive cardiac surgery. The aim of this study was to measure the rate of CPSP in patients undergoing right minithoracotomy mitral valve (MV) surgery and to compare the effectiveness of different approaches to pain control.

METHODS

A prospective observational study was conducted between March 2019 and September 2020. All patients undergoing right minithoracotomy MV surgery treated with morphine, continuous serratus anterior plane block (SAPB), or continuous erector spinae plane block (ESPB) were included. The Brief Pain Inventory questionnaire was used to evaluate 6-month CPSP and quality of life.

RESULTS

A total of 100 patients were enrolled: postoperative pain control was obtained with morphine in 26 cases, with SAPB in 37 cases, and with ESPB in 37 cases. Median intensive care unit and hospital length of stay were 1 day and 6 days, respectively. Pain severity index was lower than 10 in 81 patients, and no differences were recorded between groups (p = .59). No patients reported chronic use of medications for pain management or severe pain interference in daily activities at follow-up.

DISCUSSION

Right minithoracotomy approach is not burdened by a high incidence of CPSP: pain severity index was lower than 10 in more than 90% of patients. Then, in our experience, chronic pain seems not to be related to the type of perioperative analgesia adopted.

Magnetic Resonance Imaging for Cerebral Micro-embolizations During Minimally Invasive Mitral Valve Surgery

The role of aortic clamping techniques on the occurrence of neurological complications after right mini-thoracotomy mitral valve surgery is still debated. Brain injuries can occur also as silent cerebral micro-embolizations (SCM), which have been linked to significant deficits in physical and cognitive functions. Aims of this study are to evaluate the overall rate of SCM and to compare endoaortic clamp (EAC) with trans-thoracic clamp (TTC). Patients enrolled underwent a pre-operative, a post-operative, and a follow-up MRI. Forty-three patients were enrolled; EAC was adopted in 21 patients, TTC in 22 patients. Post-operative SCM were reported in 12 cases (27.9%). No differences between the 2 groups were highlighted (23.8% SCM in the EAC group versus 31.8% in the TTC). MRI analysis showed post-operative SCM in nearly 30% of selected patients after right mini-thoracotomy mitral valve surgery. Subgroup analysis on different types of aortic clamping showed comparable results. CLINICAL RELEVANCE: The rate of SCM reported in the present study on patients undergoing minimally invasive MVS and RAP is consistent with data in the literature on patients undergoing cardiac surgery through median sternotomy and antegrade arterial perfusion. Moreover, no differences were reported between EAC and TTC: both the aortic clamping techniques are safe, and the choice of the surgical setting to adopt can be really done according to the patient's characteristics.

Endo-Aortic vs. Trans-Thoracic Clamping in Right Mini-Thoracotomy Mitral Valve Surgery: Outcome on Myocardial Protection

Background: Perfusion strategies and aortic clamping techniques for right mini-thoracotomy mitral valve (MV) surgery have evolved over time and remarkable short- and long-term results have been reported. However, some concerns have raised about the adequacy of myocardial protection during the minimally invasive approach, particularly with the endo-aortic clamp (EAC). Aim of this study was to compare the efficacy, in terms of myocardial preservation, of the EAC with the trans-thoracic aortic clamp (TTC) in patients undergoing right mini-thoracotomy MV surgery. Methods: A single center, prospective observational study was performed on patients undergoing right mini-thoracotomy MV surgery with retrograde arterial perfusion and EAC or TTC. A propensity matched analysis was performed to compare the two groups. Primary outcome was the comparison between cardiac troponin T levels measured at different time-points after surgery. Results: Eighty EAC patients were compared with 37 TTC patients. No cases of myocardial infarction or low cardiac-output syndrome were overall reported. No differences were recorded in terms of stroke, peri-operative mortality, and in the release of myocardial markers, lactates levels and need for inotropic support at different time-points after surgery. CK-MB peak levels were significantly lower in the EAC group. Conclusion: Despite concerns arising about the EAC, this prospective study shows equivalence in terms of myocardial preservation of the EAC compared with the TTC in patients undergoing right mini-thoracotomy MV surgery.

A case report of an interrupted inferior vena cava and azygos continuation: implications for preoperative screening in minimally invasive cardiac surgery

Background

Femoral cannulation is commonly used in minimally invasive cardiac surgery to establish extracorporeal circulation. We present a case with a finding that should be evaluated when screening candidates for minimally invasive cardiac surgery.

Case summary

A 57-year-old male patient was scheduled for minimally invasive repair of the mitral and tricuspid valve and a MAZE procedure. During surgery there was difficulty advancing the venous cannula inserted in the right femoral vein. On transoesophageal echocardiography a guidewire advanced from the femoral vein was observed entering the right atrium from the superior vena cava. Despite inserting a second venous cannula in the jugular vein, venous drainage was insufficient for minimal invasive surgery. The approach was converted to a median sternotomy with bicaval cannulation. Re-examination of the preoperative computed tomography (CT) scan showed an interrupted inferior vena cava (IVC) with azygos continuation.

Discussion

In patients with major venous malformations such as the interrupted IVC with azygos continuation a full sternotomy is the preferred approach. The venous system should be evaluated when screening candidates for minimally invasive mitral valve surgery with preoperative CT. Additional cues to suspect interruption of the IVC are polysplenia and a broad superior mediastinal projection on the chest radiograph, mimicking a right paratracheal mass.

Antegrade Perfusion for Mini-Thoracotomy Mitral Valve Surgery in Patients with Atherosclerotic Burden

BACKGROUND

The relationship between retrograde arterial perfusion and stroke in patients with peripheral vascular disease has been widely documented. Antegrade arterial perfusion has been favoured as an alternative approach in less invasive mitral valve (MV) operations. We aimed to analyse our experience in patients with peripheral arterial disease undergoing MV surgery through a right mini-thoracotomy adopting antegrade arterial perfusion.

METHOD

A single-institution retrospective study on prospectively collected data was performed on patients undergoing right mini-thoracotomy MV surgery with antegrade arterial perfusion. Since 2009, indication for the latter was dictated by the severity of atherosclerotic burden. Preoperative screening included computed tomography, angiography, or both for the evaluation of the aorta and ileo-femoral arteries.

RESULTS

Consecutive patients (n=117) underwent MV surgery through a right mini-thoracotomy with antegrade arterial perfusion, established either by transthoracic central aortic cannulation in 65 (55.6%) cases or by axillary arterial cannulation in 52 (44.4%). Mean logistic EuroSCORE was 11%±2.3%. Twenty-five (25) (21.4%) patients had undergone one or more previous cardiac operations. Operative mortality was 4.3% (n=5). Nonfatal iatrogenic aortic dissection occurred in one case (0.8%). The incidence of stroke was zero.

CONCLUSIONS

Axillary or central aortic cannulation is a promising alternative route to provide excellent arterial perfusion in right mini-thoracotomy MV surgery, with a very low incidence of stroke and other major perioperative complications in patients with severe aortic or peripheral arterial disease.

Intimal aortic atherosclerosis in cardiac surgery: surgical strategies to prevent embolic stroke

 

OBJECTIVES

Although the incidence of perioperative stroke after cardiac surgery gradually decreased over the last decades, there is much variation between centres. This review aimed to create a concise overview of the evidence on possible surgical strategies to prevent embolic stroke in patients with intimal aortic atherosclerosis.

METHODS

The PubMed and EMBASE databases were searched for studies on surgical management of aortic atherosclerosis and the association with perioperative stroke in cardiac surgery, including specific searches on the most common types of surgery. Articles were screened with emphasis on studies comparing multiple strategies and studies reporting on the patients’ severity of aortic atherosclerosis. The main findings were summarized in a figure, with a grade of the corresponding level of evidence.

RESULTS

Regarding embolic stroke risk, aortic atherosclerosis of the tunica intima is most relevant. Although several strategies in general cardiac surgery seem to be beneficial in severe disease, none have conclusively been proven most effective. Off-pump surgery in coronary artery bypass grafting should be preferred with severe atherosclerosis, if the required expertise is present. Although transcatheter aortic valve replacement is used as an alternative to surgery in patients with a porcelain aorta, the risk profile concerning intimal atherosclerosis remains poorly defined.

CONCLUSIONS

A tailored approach that uses the discussed alternative strategies in carefully selected patients is best suited to reduce the risk of perioperative stroke without compromising other outcomes. More research is needed, especially on the perioperative stroke risk in patients with moderate aortic atherosclerosis.

Systematic Review of Minimally Invasive Surgery for Mitral Valve Infective Endocarditis

OBJECTIVE

The scope of application of minimally invasive mitral valve surgery is expanding. However, the safety and efficacy of minimally invasive mitral valve surgery in the setting of infective endocarditis is not well known. We sought to identify the best evidence available to support a minimally invasive surgical approach for mitral valve infective endocarditis.

METHODS

A systematic review of minimally invasive mitral valve surgery for infective endocarditis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 6 manuscripts describing 271 patients were identified. Mean age was 60.4 ± 14.9 years old, and 60.1% patients were male. Mean EuroSCORE II was 24.6 ± 23.2. Mitral valve repair was achieved in 32.4% of cases. The average in-hospital mortality was 9.4%, and average length of hospital stay was 21.6 days. Survival was 89.1% at 30 days, and 1-year survival was 79.3%. Rate of conversion to sternotomy was 1.8%. Postoperative complications included: 6.9% postoperative bleeding, 9.3% new postoperative dialysis, 2.3% postoperative stroke, and 3.4% recurrence of endocarditis. Reoperation over the long-term was required in 9.3% of cases.

CONCLUSIONS

Minimally invasive mitral valve surgery for infective endocarditis has acceptable perioperative morbidity as well as short- and intermediate-term mortality at experienced centers. Minimally invasive mitral valve surgery may be an acceptable alternative approach to infective endocarditis and warrants further study.

Impact of standardized computed tomographic angiography for minimally invasive mitral and tricuspid valve surgery

Background

Femoral cannulation for extracorporeal circulation (ECC) is a standard procedure for minimally invasive cardiac surgery (MICS) of the atrio-ventricular valves. Vascular pathologies may cause serious complications. Preoperative computed tomography-angiography (CT-A) of the aorta, axillary and iliac arteries was implemented at our department.

Methods

Between July 2017 and December 2018 all MICS were retrospectively reviewed (n = 143), and divided into 3 groups.

Results

In patients without CT (n = 45, 31.5%) ECC was applied via femoral arteries (91.1% right, 8.9% left). Vascular related complications (dissection, stroke, coronary and visceral ischemia, related in-hospital death) occurred in 3 patients (6.7%). In patients with non-contrast CT (n = 35, 24.5%) only femoral cannulation was applied (94.3% right) with complications in 4 patients (11.4%). CT-angiography (n = 63, 44.1%) identified 12 patients (19.0%) with vulnerable plaques, 7 patients (11.1%) with kinking of iliac vessels, 41 patients (65.1%) with multiple calcified plaques and 5 patients (7.9%) with small femoral artery diameter (d ≤ 6 mm). In 7 patients (11.1%) pathologic findings led to alternative cannulation via right axillary artery, additional 4 patients (6.3%) were cannulated via left femoral artery. Only 2 patients (3.2%) suffered from complications.

Conclusions

CT-A identifies vascular pathologies otherwise undetectable in routine preoperative preparation. A standardized imaging protocol may help to customize the operative strategy.

Right mini-thoracotomy approach for grown-up congenital heart disease

BACKGROUND

Right mini-thoracotomy cardiac surgery has been recognized as a safe and effective procedure, with remarkable early and long-terms outcomes. However, most of the literature is focused on mitral valve surgery and few studies report on the minimally invasive approach applied to congenital disease. Aim of this study was to review our experience on patients with grown-up congenital heart (GUCH) undergoing right mini-thoracotomy cardiac surgery.

METHODS

Data of patients with GUCH undergoing right mini-thoracotomy cardiac surgery from 2006 to 2019 were retrospectively analyzed. Inclusion criteria were atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, and mitral or tricuspid valve dysfunction in congenital heart diseases.

RESULTS

During the study period 127 patients with GUCH underwent right mini-thoracotomy cardiac surgery. Mean age was 43.6 years and more than 60% were females; diagnosis was atrial septal defect in 57 cases (44.9%); 24 patients were redo (18.9%). No cases of stroke and major vascular complications were reported. Conversion to sternotomy was required in one case (0.8%). No residual shunts or valves dysfunction were recorded at the postoperative echocardiographic evaluation. Perioperative mortality was 1.6%.

CONCLUSIONS

Right mini-thoracotomy cardiac surgery in selected patients with GUCH allows to avoid the big scar of the sternotomy approach and to accelerate the recovery in a young population. Moreover, in redo cases, it allows the surgeon to reach the heart and the aorta avoiding the well-known risks of a re-sternotomy procedure.

Transthoracic clamp versus endoaortic balloon occlusion in minimally invasive mitral valve surgery: a systematic review and meta-analysis

This systematic review and meta-analysis aims to determine outcomes following aortic occlusion with the transthoracic clamp (TTC) versus endoaortic balloon occlusion (EABO) in patients undergoing minimally invasive mitral valve surgery. A subgroup analysis compares TTC to EABO with femoral cannulation separately from EABO with aortic cannulation. We searched Medline and Embase up to December 2018. Two people independently and in duplicate screened title and abstracts, full-text reports, extracted data and assessed the risk of bias using the Cochrane risk-of-bias tool for non-randomized studies. We identified 1564 reports from which 11 observational studies with 4181 participants met the inclusion criteria. We found no evidence of difference in the risk of postoperative death or cerebrovascular accident (CVA) between the 2 techniques. Evidence for a reduction in aortic dissection with TTC was found: 4 of 1590 for the TTC group vs 19 of 2492 for the EABO group [risk ratio 0.33, 95% confidence interval (CI) 0.12-0.93; P = 0.04]. There was no difference in aortic cross-clamp (AoX) time between TTC and EABO [mean difference (MD) -5.17 min, 95% CI -12.40 to 2.06; P = 0.16]. TTC was associated with a shorter AoX time compared to EABO with femoral cannulation (MD -9.26 min, 95% CI -17.00 to -1.52; P = 0.02). EABO with aortic cannulation was associated with a shorter AoX time compared to TTC (MD 7.77 min, 95% CI 3.29-12.26; P < 0.001). There was no difference in cardiopulmonary bypass (CPB) time between TTC and EABO with aortic cannulation (MD -4.98 min, 95% CI -14.41 to 4.45; P = 0.3). TTC was associated with a shorter CPB time compared to EABO with femoral cannulation (MD -10.08 min, 95% CI -19.93 to -0.22; P = 0.05). Despite a higher risk of aortic dissection with EABO, the rates of survival and cerebrovascular accident across the 2 techniques are similar in minimally invasive mitral valve surgery.

Long-term results of endoclamping in patients undergoing minimally invasive mitral valve surgery where external aortic clamping cannot be used - a propensity matched analysis

Background

Minimally invasive mitral valve surgery is standard of care in many centres and it is commonly associated with the need for cardiopulmonary bypass. Conventional external aortic clamping (exoclamping) is not always feasible, so endoaortic clamping (endoclamping) has evolved as a viable alternative. The aim of this study is to compare endoclamping (Intraclude™, Edwards Lifesciences) with exoclamping (Chitwood) during minimally invasive mitral valve procedures.

Methods

This single-centre study included 822 consecutive patients undergoing minimally invasive mitral valve procedures. The endoclamp was used in 64 patients and the exoclamp in 758. Propensity-score (PS) matching was performed resulting in 63 patients per group. Outcome measures included procedural variables, length of intensive care unit (ICU) and hospital stay, major adverse cardiac and cerebrovascular events (MACCE) and repeat surgery.

Results

The mean age was similar in the two group (62.2 [endoclamp] vs. 63.5 [exoclamp] years; p = 0.554), as were the cardiopulmonary bypass (145 vs. 156 min; p = 0.707) and the procedure time (203 vs. 211 min; p = 0.648). The X-clamp time was significantly shorter in the endoclamp group (88 vs. 99 min; p = 0.042). Length of ICU stay (25.0 vs. 23.0 h) and length of hospital stay (10.0 vs. 9.0 days) were slightly longer in the endoclamp group, but without statistical significance. There were nominal but no statistically significant differences between the groups in the rates of stroke, vascular complications, myocardial infarction or repeat mitral valve surgery. The conversion rate to open sternotomy approach was 2.4% without difference between groups. The estimated 7-year survival rate was similar for both groups (89.9% [endoclamp]; 84.0% [exoclamp]) with a hazard ratio of 1.291 (95% CI 0.453–3.680).

Conclusions

Endoaortic clamping is an appropriate and reasonably safe alternative to the conventional Chitwood exoclamp for patients in which the exoclamp cannot be used because the ascending aorta cannot be safely mobilised.

Contemporary Reoperative Mitral Valve Surgery: Technical Considerations and Clinical Outcomes

As patients with cardiac disease live longer, reoperative mitral valve surgery has become more common. Although these operations are technically challenging and of high risk, outcomes continue to improve. Minimally invasive techniques, better cardioprotective strategies, and advanced perioperative care have contributed to this. In this review, we discuss surgical approaches, intraoperative strategies, novel catheter-directed devices, and clinical outcomes of contemporary reoperative mitral valve surgery.

Clinical outcomes associated with retrograde arterial perfusion in minimally invasive mitral valve surgery: a systematic review

INTRODUCTION

Given several reports of an increased neurologic risk with retrograde arterial perfusion in minimally invasive mitral valve surgery, we sought to identify and synthesize the best available evidence on the influence of perfusion strategy on post-operative clinical outcomes in this population.

METHODS

A systematic search of PubMed, EMBASE, MEDLINE, and Cochrane library databases was performed to identify publications comparing clinical outcomes associated with antegrade and retrograde arterial perfusion in minimally invasive mitral valve surgery. Pre-specified outcomes of interest were neurologic events, mortality, and renal failure. The search was performed by two independent reviewers, with data abstraction following.

RESULTS

Seven observational studies were included in this review, with a total patient population of 5,385. Six were retrospective cohort in design, with a single small prospective cohort study identified. When available, adjusted publication-specific risk estimates were abstracted and included preferentially over unadjusted or reviewer-derived risk estimates. Meta-analysis was felt to be heavily flawed in the context of few small studies identified and was not performed. In adjusted estimates, there appeared to be an increased risk of neurologic complications with retrograde arterial perfusion. There was a null pattern apparent between arterial perfusion strategy and each of 30-day mortality and renal failure.

CONCLUSION

Retrograde arterial perfusion in minimally invasive mitral valve surgery may be associated with an increased risk of neurologic events, without affecting the risk of 30-day mortality or renal failure. Although these patterns were identified, an overall paucity of evidence justifies further study.

Reoperative mitral valve replacement via right mini-thoracotomy with ventricular fibrillatory arrest for a patient with severely calcified aortic homograft

We successfully performed reoperative mitral valve replacement (MVR) for a patient with a previous extensive cardiac surgery that included aortic homograft replacement for aortic and mitral valve endocarditis complicated with aortic root abscess. The aortic homograft function was well preserved without aortic insufficiency, although the homograft was highly calcified. We used a right mini-thoracotomy approach and ventricular fibrillatory arrest to avoid an aortic cross-clamping. Only minimal dissection was needed to obtain enough exposure to perform the redo MVR. The reduction in invasiveness helped to prevent major injury during the surgery, shortened the cardiopulmonary bypass and operation time, and facilitated the patient's recovery. Right mini-thoracotomy with ventricular fibrillatory arrest is a viable option for reoperative MVR in patients with previous sternotomy and unclampable aorta.

Left Atrial Function after Atrial Fibrillation Cryoablation Concomitant to Minimally Invasive Mitral Valve Repair: A Pilot Study on Long-Term Results and Clinical Implications

Background and Objectives: Surgical atrial fibrillation (AF) ablation concomitant to minimally invasive mitral valve repair has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to mitral valve surgery only. The objective of the present study was to explore, by thorough echocardiographic assessment, long-term morphological and functional left atrial (LA) outcomes after this combined surgical procedure. Materials and Methods: From October 2006 to November 2015, 48 patients underwent minimally invasive mitral valve repair and concomitant surgical AF cryoablation. Results: After 3.8 ± 2.2 years, 30 (71.4%) of those completing the follow-up (n = 42, 87.5%) presented SR. During follow-up, four (9.5%) patients suffered from cerebrovascular accidents and two of these subjects had a long-standing persistent AF relapse and were in AF at the time of the event, while the other two were in SR. An echocardiographic study focused on LA characteristics was performed in 29 patients (69.0%). Atrial morphology and function (e.g., maximal LA volume indexed to body surface area and total LA emptying fraction derived from volumes) in patients with stable SR (60.6 ± 13.1 mL/mq and 25.1 ± 7.3%) were significantly better than in those with AF relapses (76.8 ± 16.2 mL/mq and 17.5 ± 7.4%; respectively, p = 0.008 and p = 0.015). At follow-up, patients who suffered from ischemic cerebral events had maximal LA volume indexed to body surface area 61 ± 17.8 mL/mq, with total LA emptying fraction derived from volumes 23.6 ± 13.7%; patients with strokes in SR showed very enlarged LA volume (>70 mL/mq). Conclusions: AF cryoablation concomitant with minimally invasive mitral valve repair provides a high rate of SR maintenance and this relates to improved long-term morphological and functional LA outcomes. Further prospective studies are needed to define the cut-off values determining an increase in the risk for thromboembolic complications in patients with restored stable SR.

Steps Forward in Minimally Invasive Cardiac Surgery: 10-Year Experience

BACKGROUND

Minimally invasive cardiac surgery (MICS) has constantly evolved over the past years, and new technologies have been introduced. The aims of this study were to analyze the evolution of our 10-year experience in MICS and to highlight outcomes in different spans of time.

METHODS

Patients undergoing MICS for mitral valve, tricuspid valve, and/or atrial septal defect or atrial masses from November 2005 to November 2015 were retrospectively analyzed. A comparative analysis was performed by identifying 2 groups: the control group (in the first time span of our experience) and the tailored group (patients who underwent surgery after a full preoperative anatomic evaluation with allocation to the proper setting).

RESULTS

During the study period 971 patients underwent MICS. MICS procedures increased from 44% in 2006 to 96% in 2015. Subgroup analysis revealed a significant decrease in the rate of procedures performed with retrograde arterial perfusion (99.1% vs 91.7%, P < .0001), a significant increase in the rate of complex mitral valve procedures (22.4% vs 7.9%, P < .0001), and a significant decrease in the rate of stroke (from 5.2% to 1%, P < .001) in the tailored group. The logistic regression analysis showed that the tailored approach was a protective factor against neurologic complications.

CONCLUSIONS

The present study shows the considerable and attractive results of our decision-making process based on the tailored approach. The 10-year outcome analysis demonstrated a trend toward a progressive decrease in the overall rate of postoperative complications and a significant protective effect of the tailored approach on the occurrence of stroke.

Magnetic resonance imaging for cerebral lesions during minimal invasive mitral valve surgery: study protocol for a randomized controlled trial

BACKGROUND

Recent data have highlighted a higher rate of neurological injuries in minimal invasive mitral valve surgery (MIMVS) compared with the standard sternotomy approach; therefore, the role of specific clamping techniques and perfusion strategies on the occurrence of this complication is a matter of discussion in the medical literature. The purpose of this trial is to prospectively evaluate major, minor and silent neurological events in patients undergoing right mini-thoracotomy mitral valve surgery using retrograde perfusion and an endoaortic clamp or a transthoracic clamp.

METHODS/DESIGN

A prospective, blinded, randomized controlled study on the rate of neurological embolizations during MIMVS started at the University of Turin in June 2014. Major, minor and silent neurological events are being investigated through standard neurological evaluation and magnetic resonance imaging assessment. The magnetic resonance imaging protocol includes conventional sequences for the morphological and quantitative assessment and nonconventional sequences for the white matter microstructural evaluation. Imaging studies are performed before surgery as baseline assessment and on the third postoperative day and, in patients who develop postoperative ischemic lesions, after 6 months.

DISCUSSION

Despite recent concerns raised about the endoaortic setting with retrograde perfusion, we expect to show equivalence in terms of neurological events of this technique compared with the transthoracic clamp in a selected cohort of patients. With the first results expected in December 2016 the findings would be of help in confirming the efficacy and safety of MIMVS.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02818166 . Registered on 8 February 2016 - trial retrospectively registered.