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Helms F, Deniz E, Krüger H, Zubarevich A, Schmitto JD, Poyanmehr R, Hinteregger M, Martens A, Weymann A, Ruhparwar A, Schmack B, Popov AF. Minimally Invasive Approach for Replacement of the Ascending Aorta towards the Proximal Aortic Arch. J Clin Med 2024; 13:3274. [PMID: 38892985 PMCID: PMC11172865 DOI: 10.3390/jcm13113274] [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: 04/26/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives: In recent years, minimally invasive approaches have been used with increasing frequency, even for more complex aortic procedures. However, evidence on the practicability and safety of expanding minimally invasive techniques from isolated operations of the ascending aorta towards more complex operations such as the hemiarch replacement is still scarce to date. Methods: A total of 86 patients undergoing elective surgical replacement of the ascending aorta with (n = 40) or without (n = 46) concomitant proximal aortic arch replacement between 2009 and 2023 were analyzed in a retrospective single-center analysis. Groups were compared regarding operation times, intra- and postoperative complications and long-term survival. Results: Operation times and ventilation times were significantly longer in the hemiarch replacement group. Despite this, no statistically significant differences between the two groups were observed for the duration of the ICU and hospital stay and postoperative complication rates. At ten-year follow-up, overall survival was 82.6% after isolated ascending aorta replacement and 86.3% after hemiarch replacement (p = 0.441). Conclusions: Expanding the indication for minimally invasive aortic surgery towards the proximal aortic arch resulted in comparable postoperative complication rates, length of hospital stay and overall long-term survival compared to the well-established minimally invasive isolated supracommissural ascending aorta replacement.
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Affiliation(s)
- Florian Helms
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Ezin Deniz
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Heike Krüger
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Alina Zubarevich
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jan Dieter Schmitto
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Reza Poyanmehr
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Martin Hinteregger
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Andreas Martens
- Clinic for Cardiac Surgery, University Clinic Oldenburg, 26129 Oldenburg, Germany
| | - Alexander Weymann
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Arjang Ruhparwar
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Bastian Schmack
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Aron-Frederik Popov
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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2
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Tchana-Sato V, Bruls S, Minga Lowampa E, Houben A, Desiron Q, Hans G, Lagny MG, Jaquet O, Defraigne JO, Lavigne JP. Surgery of the ascending aorta via a right anterior minithoracotomy: initial surgical experience of a single center. Acta Chir Belg 2024; 124:28-34. [PMID: 36424303 DOI: 10.1080/00015458.2022.2152240] [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: 07/07/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES Full median sternotomy (FMS) is the common surgical access for patients undergoing replacement of the ascending aorta (AA) with or without aortic valve replacement (AVR). The right anterior mini-thoracotomy (RAMT) approach has been increasingly adopted for AVR. This approach has been shown to decrease blood loss and hospital length of stay (LOS) compared with FMS. The RAMT approach may also be beneficial in selected patients requiring AA procedures with or without AVR. We present our initial clinical experience of patients who have undergone a RAMT for supracommissural replacement of the tubular AA with or without AVR. METHODS This is a single-center retrospective review of 10 patients who underwent an elective RAMT for replacement of the tubular AA with or without AVR between November 2019 and January 2022. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital LOS, time to extubation, operative times, as well as postoperative complications such as stroke and bleeding. RESULTS Median cross-clamp and cardiopulmonary bypass times were 109 and 148 min, respectively. Median time to extubation was 2.5 h and median intensive care unit and hospital stay were 2 and 10 days, respectively. There were two re-thoracotomies for postoperative bleeding and two cases of sub-xiphoidal pericardial drainage for pericardial effusion. There were no strokes and no in-hospital nor 30-day mortalities. CONCLUSIONS The replacement of the AA with or without concomitant AVR can be performed through a RAMT in carefully selected patients. However, the safety of this approach, as compared to full/partial median sternotomy, remains to be proven.
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Affiliation(s)
| | - Samuel Bruls
- Department of Cardiovascular Surgery, CHU Liege, Liege, Belgium
| | | | - Alan Houben
- Department of Anesthesiology, CHU Liege, Liege, Belgium
| | - Quentin Desiron
- Department of Cardiovascular Surgery, CHU Liege, Liege, Belgium
| | - Gregory Hans
- Department of Anesthesiology, CHU Liege, Liege, Belgium
| | | | - Oceane Jaquet
- Department of Anesthesiology, CHU Liege, Liege, Belgium
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3
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Freundlich RE, Clifton JC, Epstein RH, Pandharipande PP, Grogan TR, Moore RP, Byrne DW, Fabbro M, Hofer IS. External validation of a predictive model for reintubation after cardiac surgery: A retrospective, observational study. J Clin Anesth 2024; 92:111295. [PMID: 37883900 PMCID: PMC10872431 DOI: 10.1016/j.jclinane.2023.111295] [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: 06/08/2023] [Revised: 08/24/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023]
Abstract
STUDY OBJECTIVE Explore validation of a model to predict patients' risk of failing extubation, to help providers make informed, data-driven decisions regarding the optimal timing of extubation. DESIGN We performed temporal, geographic, and domain validations of a model for the risk of reintubation after cardiac surgery by assessing its performance on data sets from three academic medical centers, with temporal validation using data from the institution where the model was developed. SETTING Three academic medical centers in the United States. PATIENTS Adult patients arriving in the cardiac intensive care unit with an endotracheal tube in place after cardiac surgery. INTERVENTIONS Receiver operating characteristic (ROC) curves and concordance statistics were used as measures of discriminative ability, and calibration curves and Brier scores were used to assess the model's predictive ability. MEASUREMENTS Temporal validation was performed in 1642 patients with a reintubation rate of 4.8%, with the model demonstrating strong discrimination (optimism-corrected c-statistic 0.77) and low predictive error (Brier score 0.044) but poor model precision and recall (Optimal F1 score 0.29). Combined domain and geographic validation were performed in 2041 patients with a reintubation rate of 1.5%. The model displayed solid discriminative ability (optimism-corrected c-statistic = 0.73) and low predictive error (Brier score = 0.0149) but low precision and recall (Optimal F1 score = 0.13). Geographic validation was performed in 2489 patients with a reintubation rate of 1.6%, with the model displaying good discrimination (optimism-corrected c-statistic = 0.71) and predictive error (Brier score = 0.0152) but poor precision and recall (Optimal F1 score = 0.13). MAIN RESULTS The reintubation model displayed strong discriminative ability and low predictive error within each validation cohort. CONCLUSIONS Future work is needed to explore how to optimize models before local implementation.
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Affiliation(s)
- Robert E Freundlich
- Vanderbilt University Medical Center, Departments of Anesthesiology and Biomedical Informatics, 1211 21(st) Avenue South, Nashville, TN 37212, USA.
| | - Jacob C Clifton
- Vanderbilt University Medical Center, Department of Anesthesiology, 1211 21(st) Avenue South, Nashville, TN 37212, USA.
| | | | - Pratik P Pandharipande
- Vanderbilt University Medical Center, Departments of Anesthesiology and Surgery, 1211 21(st) Avenue South, Nashville, TN 37212, USA.
| | - Tristan R Grogan
- University of California, Los Angeles, Department of Anesthesiology, Los Angeles, CA, USA
| | - Ryan P Moore
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN, USA.
| | - Daniel W Byrne
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN, USA.
| | - Michael Fabbro
- University of Miami, Department of Anesthesiology, Miami, FL, USA
| | - Ira S Hofer
- University of California, Los Angeles, Department of Anesthesiology, Los Angeles, CA, USA
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4
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Helms F, Schmack B, Weymann A, Hanke JS, Natanov R, Martens A, Ruhparwar A, Popov AF. Expanding the Minimally Invasive Approach towards the Ascending Aorta-A Practical Overview of the Currently Available Techniques. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1618. [PMID: 37763737 PMCID: PMC10534602 DOI: 10.3390/medicina59091618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
Minimally invasive techniques have gained immense importance in cardiovascular surgery. While minimal access strategies for coronary and mitral valve surgery are already widely accepted and often used as standard approaches, the application of minimally invasive techniques is currently expanded towards more complex operations of the ascending aorta as well. In this new and developing field, various techniques have been established and reported ranging from upper hemisternotomy approaches, which allow even extensive operations of the ascending aorta to be performed through a minimally invasive access to sternal sparing thoracotomy strategies, which completely avoid sternal trauma during ascending aorta replacements. All of these techniques place high demands on patient selection, preoperative planning, and practical surgical implementation. Application of these strategies is currently limited to high-volume centers and highly experienced surgeons. This narrative review gives an overview of the currently available techniques with a special focus on the practical execution as well as the advantages and disadvantages of the currently available techniques. The first results demonstrate the practicability and safety of minimally invasive techniques for replacement of the ascending aorta in a well-selected patient population. With success and complication rates comparable to classic full sternotomy, the proof of concept for minimally invasive replacement of the ascending aorta is now achieved.
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Affiliation(s)
- Florian Helms
- Division for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
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5
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Berretta P, Chiuselli G, Galeazzi M, Codecasa R, Alfonsi J, Braconi L, Bifulco O, Rapisarda F, Malvindi PG, Bonacchi M, Stefano P, Di Eusanio M. Comparison of minimally invasive versus conventional thoracic aortic operations: Early and midterm results in a series of 624 patients. J Card Surg 2022; 37:4732-4739. [PMID: 36378935 DOI: 10.1111/jocs.17142] [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: 08/07/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Despite minimally invasive techniques having gained wider application in cardiac surgery, current evidence on minithoracic aortic surgery is still limited. The aim of this study was to compare early and midterm outcomes of patients undergoing operations of the proximal thoracic aorta through ministernotomy (MS) versus full sternotomy (FS). METHODS Data from 624 consecutive patients who underwent proximal aortic repair through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at two aortic centers were analyzed. Treatment selection bias was addressed using propensity score matching (MS vs. FS). After matching, two well-balanced groups of 202 patients each were created. RESULTS Median cardiopulmonary bypass and cross-clamp times were 88 and 68 min, respectively, with no difference between groups. Overall, 30-day mortality was 1% (n = 2) in MS and 0.5% (n = 1) in FS (p = .6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4, 2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%). Patients receiving MS showed a lower incidence of respiratory insufficiency compared with FS (0% vs. 2.5%, p = .04). Intensive care unit and hospital stays were similar between groups. Two-year survival rate was 97.2% in MS and 96.5% in FS (p = .9). CONCLUSIONS Mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Giulia Chiuselli
- Cardiac Surgery Unit, Careggi University Hospital, Firenze, Italy
| | - Michele Galeazzi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy.,Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | | | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Lucio Braconi
- Cardiac Surgery Unit, Careggi University Hospital, Firenze, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy.,Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Fabio Rapisarda
- Cardiac Surgery Unit, Careggi University Hospital, Firenze, Italy
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Massimo Bonacchi
- Cardiac Surgery Unit, Careggi University Hospital, Firenze, Italy
| | | | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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6
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Nishida T, Kono T, Takagi K, Tayama E. Right-parasternal approach for aortic valve replacement and ascending aortic repair after ante-thoracic route gastric tube reconstruction. J Card Surg 2022; 37:5505-5508. [PMID: 36259759 DOI: 10.1111/jocs.17052] [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: 09/03/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 01/06/2023]
Abstract
Due to the limitations of surgical incisions and approaches brought on by the presence of gastric tube (GT), open heart surgery following ante-thoracic route GT reconstruction remains challenging. A-73-year-old man, who had a history of esophageal resection and ante-thoracic route GT reconstruction required aortic valve replacement (AVR) concomitant with ascending aortic repair (AAR) for aortic stenosis and dilated ascending aorta. We performed open heart surgery via a right-parasternal approach to avoid injury to the GT and nutrient arteries. This approach provided a good operative field, similar to median sternotomy. To our knowledge, this is the first case of AVR concomitant with AAR after ante-thoracic route GT reconstruction via a right-parasternal approach. We consider that the right-parasternal approach is reasonable for patients with ante-thoracic route GT reconstruction.
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Affiliation(s)
- Takamichi Nishida
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, Kurume City, Fukuoka, Japan
| | - Takanori Kono
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, Kurume City, Fukuoka, Japan
| | - Kazuyoshi Takagi
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, Kurume City, Fukuoka, Japan
| | - Eiki Tayama
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, Kurume City, Fukuoka, Japan
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7
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VAN Kampen A, Kofler M, Meyer A, Gerber M, Sündermann SH, VAN Praet KM, Akansel S, Hommel M, Falk V, Kempfert J. Aortic valve replacement via right anterolateral minithoracotomy: preventing adverse events during the initial learning curve. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:85-90. [PMID: 34825793 DOI: 10.23736/s0021-9509.21.11981-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Despite excellent outcomes and reduced invasiveness, the right anterolateral thoracotomy approach for aortic valve replacement (RALT-AVR) has not been broadly adopted. This study provides results regarding the initial experience and learning curve of a single surgeon performing this procedure. METHODS Periprocedural details and postoperative outcomes of the first 100 consecutive patients who underwent RALT-AVR at our institution were retrospectively analyzed. We conducted a cumulative sum analysis of surgical failure, defined as occurrence of 30-day-mortality, surgical revision for bleeding, conversion to sternotomy, 3rd degree heart block, paravalvular leakage, postoperative stroke or mean transvalvular gradient >20 mmHg. RESULTS The cohort was of low surgical risk (mean EuroSCORE II 1.31%±0.85, mean STS PROM 1.45%±0.97), 58% were males. Median cross-clamp time was 67.5 (57.8-76) min, median CPB time 105 (91.8-119) min, and median operation time 164.5 (144.5-183.2) min. There were no conversions to full sternotomy, 4 cases of revision for bleeding and 2 pacemaker implantations for 3rd degree heart block. Prosthesis function was good (median ΔPmean 10.9 [7.4-13.6] mmHg). Thirty-day-mortality was 0%. The log-likelihood graph never crossed the upper boundary, and after a steady decrease, crossed the lower boundary at 93 patients. CONCLUSIONS RALT-AVR can be performed with acceptable procedural times and satisfactory outcomes. For a well-trained surgeon, adapting to this new procedure does not expose patients to an increased risk, when patient selection and procedural planning are applied appropriately. Cumulative sum failure analysis is an appropriate tool to monitor the transition from standard AVR to the technically more demanding RALT-AVR.
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Affiliation(s)
- Antonia VAN Kampen
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany -
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany -
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany -
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Maria Gerber
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Simon H Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité University Hospital, Berlin, Germany
| | - Karel M VAN Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Serdar Akansel
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Matthias Hommel
- Department of Anesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité University Hospital, Berlin, Germany
- Department of Health Sciences and Technology, Translational Cardiovascular Technologies, Institute of Translational Medicine, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité University Hospital, Berlin, Germany
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8
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Torregrossa G, Sá MP, Van den Eynde J, Malin JH, Sicouri S, Wertan MC, Ramlawi B, Sutter FP. Hybrid robotic off‐pump versus conventional on‐pump and off‐pump coronary artery bypass graft surgery in women. J Card Surg 2022; 37:895-905. [DOI: 10.1111/jocs.16247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/24/2021] [Accepted: 12/25/2021] [Indexed: 01/26/2023]
Affiliation(s)
- Gianluca Torregrossa
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - Michel Pompeu Sá
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences Katholieke Universiteit Leuven Leuven Belgium
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine Baltimore Maryland USA
| | - John H. Malin
- Philadelphia College of Osteopathic Medicine Bala Cynwyd Pennsylvania USA
| | - Serge Sicouri
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - MaryAnn C. Wertan
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
| | - Basel Ramlawi
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - Francis P. Sutter
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
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9
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Minimally invasive approach: is this the future of aortic surgery? Indian J Thorac Cardiovasc Surg 2021; 38:171-182. [PMID: 35463712 PMCID: PMC8980970 DOI: 10.1007/s12055-021-01258-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/03/2022] Open
Abstract
Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery.
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10
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Alnajar A, Lamelas J. Commentary: The mini-thoracotomy approach for descending aorta: Small, simple and safe! JTCVS Tech 2021; 8:31-32. [PMID: 34401801 PMCID: PMC8350798 DOI: 10.1016/j.xjtc.2021.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 04/18/2021] [Accepted: 04/22/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ahmed Alnajar
- Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Joseph Lamelas
- Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
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11
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Rayner TA, Harrison S, Rival P, Mahoney DE, Caputo M, Angelini GD, Savović J, Vohra HA. Minimally invasive versus conventional surgery of the ascending aorta and root: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2021; 57:8-17. [PMID: 31209468 DOI: 10.1093/ejcts/ezz177] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 01/28/2023] Open
Abstract
Limited uptake of minimally invasive surgery (MIS) of the aorta hinders assessment of its efficacy compared to median sternotomy (MS). The objective of this systematic review is to compare operative and perioperative outcomes for MIS versus MS. Online databases Medline, EMBASE, Cochrane Library and Web of Science were searched from inception until July 2018. Both randomized and observational studies of patients undergoing aortic root, ascending aorta or aortic arch surgery by MIS versus MS were eligible for inclusion. Primary outcomes were 30-day mortality, reoperation for bleeding, perioperative renal impairment and neurological events. Intraoperative and postoperative timing measures were also evaluated. Thirteen observational studies were included comparing 1101 MIS and 1405 MS patients. The overall quality of evidence was very low for all outcomes. Mortality and the incidence of stroke were similar between the 2 cohorts. Meta-analysis demonstrated increased length of cardiopulmonary bypass (CPB) time for patients undergoing MS [standardized mean difference 0.36, 95% confidence interval (CI) 0.15-0.58; P = 0.001]. Patients receiving MS spent more time in hospital (standardized mean difference 0.30, 95% CI 0.17-0.43; P < 0.001) and intensive care (standardized mean difference 0.17, 95% CI 0.06-0.27; P < 0.001). Reoperation for bleeding (risk ratio 1.51, 95% CI 1.06-2.17; P = 0.024) and renal impairment (risk ratio 1.97, 95% CI 1.12-3.46; P = 0.019) were also greater for MS patients. There was substantial heterogeneity in meta-analyses for CPB and aortic cross-clamp timing outcomes. MIS may be associated with improved early clinical outcomes compared to MS, but the quality of the evidence is very low. Randomized evidence is needed to confirm these findings.
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Affiliation(s)
- Tom A Rayner
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Sean Harrison
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Rival
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Massimo Caputo
- Department of Cardiac Surgery, Bristol Hearth Institute, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Hearth Institute, Bristol, UK
| | - Jelena Savović
- Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Hunaid A Vohra
- Department of Cardiac Surgery, Bristol Hearth Institute, Bristol, UK
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Staromłyński J, Kowalewski M, Sarnowski W, Smoczyński R, Witkowska A, Bartczak M, Drobiński D, Wierzba W, Suwalski P. Midterm results of less invasive approach to ascending aorta and aortic root surgery. J Thorac Dis 2020; 12:6446-6457. [PMID: 33282347 PMCID: PMC7711423 DOI: 10.21037/jtd-20-2165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Minimally invasive aortic valve (AV) surgery has become widely accepted alternative to standard sternotomy. Despite possible reduction in morbidity, this approach is not routinely performed for aortic surgery. Current report aimed to demonstrate early and mid-term outcomes in patients undergoing minimally invasive aortic root- and ascending aorta-replacement with or without concomitant AV replacement (AVR). Methods Between 2011 and 2018, 167 selected low- and intermediate risk patients (mean age: 64.1±11.3; 70% men; EuroSCORE II 2.58±3.26) underwent minimally invasive aortic surgery. The “V” shaped partial upper sternotomy was performed through a 6-cm skin incision. Patients were divided into minimally invasive root reimplantation/replacement/remodelling (root RRR), supracoronary aorta replacements (SCAR) and SCAR+AVR. Kaplan-Meier estimates of survival were used. Results Mean follow-up was 3.1 year (max 7.7 years). Of 167 patients, 82 (49%) underwent SCAR; 44 (26%) SCAR + AVR. Forty-one patients (25%) underwent minimally invasive root RRR. Average aortic diameter was 6.00±0.46 cm. The cardiopulmonary bypass and aortic cross-clamp time were 152.0±46.8 and 101.8±36.8 minutes. There was one conversion to sternotomy. Median intensive care unit stay was 2.0 (IQR: 1.0–3.0) days. Thirty-day mortality was 1%. Within investigated follow-up, there was one late reoperation due to aortic valve thrombosis; late survival was estimated at 95% without differences between types of surgery: hazard ratio, 0.81; 95% CI: 0.36–1.81; P=0.61. Conclusions Minimally invasive aortic surgery performed through “V” shaped partial upper sternotomy is feasible and safe in selected patients regardless of the extent of repair, from supracoronary aorta replacements to complex root surgery.
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Affiliation(s)
- Jakub Staromłyński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland.,Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland.,Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wojciech Sarnowski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Radosław Smoczyński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Anna Witkowska
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Maciej Bartczak
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Dominik Drobiński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Waldemar Wierzba
- Satellite Campus in Warsaw, University of Humanities and Economics in Łódź, Warsaw, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
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Alnajar A, Aleong EF, Azhar MZ, Azarrafiy R, Lamelas J. Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches. J Card Surg 2020; 35:3539-3544. [PMID: 33025654 DOI: 10.1111/jocs.15061] [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] [Received: 07/05/2020] [Revised: 08/23/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022]
Abstract
Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during a circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery. Hemiarch and ascending aortic surgery is associated with a higher risk of mortality and morbidity. Attention to the optimal approach and cerebral protection strategy has been shown to significantly affect outcomes and mitigate risk.
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Affiliation(s)
- Ahmed Alnajar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Elizabeth F Aleong
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Muhammad Z Azhar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ryan Azarrafiy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joseph Lamelas
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Karangelis D, Loggos S, Mitropoulos FA. Right Anterior Mini-Thoracotomy for Discrete Fibromembranous Subaortic Stenosis. World J Pediatr Congenit Heart Surg 2020; 11:664-665. [PMID: 32853081 DOI: 10.1177/2150135120932520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Discrete fibromembranous subaortic stenosis is a common type of subaortic stenosis causing clinically significant left ventricular outflow obstruction. Surgery for discrete subaortic stenosis is most often performed through a typical midline sternotomy. Herein, we present our experience with an adult patient who underwent a right mini-thoracotomy for subaortic membrane resection with central cannulation under direct operative vision.
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Affiliation(s)
- Dimos Karangelis
- Department of Cardiac Surgery, 69036Mitera Hospital, Athens, Greece
| | - Spiros Loggos
- Department of Cardiac Surgery, 69036Mitera Hospital, Athens, Greece
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15
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Etz CD, Haunschild J, Girdauskas E, Della Corte A, Fedak PWM, Schäfers HJ, Sundt TM, Borger MA. Surgical management of the aorta in BAV patients. Prog Cardiovasc Dis 2020; 63:475-481. [PMID: 32640281 DOI: 10.1016/j.pcad.2020.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 12/12/2022]
Abstract
Patients with a bicuspid aortic valve (BAV) frequently develop aneurysms of the aortic root and tubular ascending aorta. Aneurysms of the aortic arch, in the absence of concomitant aortopathies, are much less common. According to the 2018 American Association of Thoracic Surgery consensus guidelines on BAV-related aortopathy, prophylactic surgical aortic repair / replacement is recommended starting at a maximum aortic diameter of 50 mm in patients with risk factors. Concomitant aortic surgery is also recommended at an aortic diameter of 45 mm in those patients with other indications for cardiac surgery (most commonly aortic valve procedures). The ultimate goal of prophylactic aortic surgery is the prevention of aortic catastrophes, e.g. aortic rupture or acute aortic dissection, which are associated with high morbidity and mortality. The surgical technique used - in elective and emergency cases - depends on the involvement and nature of the aortic valve disease, as well as the extent of aortic aneurysm formation. The current review focusses on the surgical management of the aortic root, tubular ascending aorta, and proximal aortic arch in BAV patients. Despite the abovementioned recommendations, many BAV patients develop acute aortic syndromes below the recommended aortic diameter thresholds. Further research is therefore required in order to identify high-risk BAV subgroups that would benefit from earlier surgical repair.
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Affiliation(s)
- Christian D Etz
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Paul W M Fedak
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Canada
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Michael A Borger
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
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Right Mini-Thoracotomy Subaortic Membrane Resection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:428-432. [PMID: 30547896 DOI: 10.1097/imi.0000000000000564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Subaortic membrane is an anatomical intracardiac anomaly that may cause discrete subaortic stenosis and aortic insufficiency. Patients requiring subaortic membrane resection may benefit from a minimally invasive approach; however, subaortic membranes are typically resected through a median sternotomy. We present our initial clinical experience of adult patients who have undergone a mini-thoracotomy subaortic membrane resection. METHODS Eight patients who underwent an elective subaortic membrane resection performed through a mini-thoracotomy were retrospectively reviewed. A 5-cm mini-thoracotomy incision was made in the 2nd intercostal space; a videoscope was inserted through a separate incision within the same interspace. Cardiopulmonary bypass (CPB) was instituted via central arterial and peripheral venous cannulation and an aortotomy was made. The subaortic membrane was resected with shafted instruments. The left ventricular outflow tract was inspected and CPB was weaned. Thirty-day mortality, intensive care and hospital length of stay, ventilation time, operative times, postoperative morbidity, and need for additional procedures were evaluated. RESULTS The median CPB and cross-clamp times were 60 and 42 minutes, respectively. The median time to extubation was 3.6 hours. The median intensive care unit and hospital stay were 22 hours and 3 days, respectively. The postoperative left ventricular outflow tract mean gradients decreased significantly (26.5 vs. 9.4 mm Hg, P = 0.001). There were no conversions to sternotomy, perioperative strokes, or 30-day mortality. CONCLUSIONS Subaortic membranes can be resected through a mini-thoracotomy approach with excellent clinical results.
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Johnson CA, Melvin AL, Robinson DA, Amirjamshidi H, Knight PA, Gosev I. Titanium Fastener Utilization During HeartMate 3 Left Ventricular Assist Device Implantation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:361-364. [PMID: 30394954 DOI: 10.1097/imi.0000000000000560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the feasibility of using titanium fasteners for securement of the inflow sewing ring during HeartMate 3 implantation. The secondary objective was to compare cardiopulmonary bypass and total operative times between the titanium fastener and hand-tied knot groups. METHODS Clearance between the sewing ring and the HeartMate 3 device was assessed in vitro. Thirty-one patients undergoing HeartMate 3 implantation via median sternotomy at a single center from April 2017 to February 2018 were reviewed. The sewing ring was secured with hand-tied knots (n = 18) or titanium fasteners (n = 13). Cannulation strategy and implantation technique were otherwise identical between groups. Central arterial and venous cannulation was performed for cardiopulmonary bypass. The left ventricular apex was cored, and the sewing ring was attached with hand-tied knots or titanium fasteners. RESULTS There was adequate clearance for the titanium fastener to secure the inflow sewing ring and then connect to the HeartMate 3 in vitro. The inflow sewing ring was successfully secured during HeartMate 3 implantation in the titanium fastener group. Cardiopulmonary bypass time was 75 and 92 minutes for the titanium fastener and hand-tied groups, respectively (P < 0.03). Total operative time was 177 and 193 minutes for the titanium fastener and hand-tied groups, respectively (P = 0.513). CONCLUSIONS The inflow sewing ring of the HeartMate 3 was efficiently secured using titanium fasteners. Titanium fasteners resulted in shorter cardiopulmonary bypass times compared with the hand-tied group. There was no difference in total operative time.
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Affiliation(s)
- Carl A Johnson
- From the Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY USA
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Right Mini-thoracotomy Bentall Procedure. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:328-331. [DOI: 10.1097/imi.0000000000000555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Bentall procedures are traditionally performed through a median sternotomy. The right mini-thoracotomy approach is increasingly used in aortic valve replacement. This approach has been shown to have decreased blood loss and hospital length of stay compared with sternotomy. A right mini-thoracotomy approach may also be beneficial in selected patients requiring aortic root surgery. We present our initial clinical experience of patients who have undergone a right mini-thoracotomy Bentall. Methods This is a single-center retrospective review of seven patients who underwent a primary elective right anterior mini-thoracotomy Bentall. A thoracoscope was used in each case. Automated suturing technology was used for annular suturing in three of the seven patients. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital length of stay, time to extubation, operative times, as well as postoperative sequelae including stroke, infection, and bleeding. Results Median cardiopulmonary bypass, cross-clamp, and circulatory arrest time were 217, 153, and 28 minutes, respectively. Median time to extubation was 10 hours and median intensive care unit and hospital stay was 1 and 4 days, respectively. One patient had a wound infection and one returned to the operating room for bleeding. There were no in-hospital or 30-day mortalities. Conclusions The Bentall procedure can be performed through a right anterior mini-thoracotomy in selected patients with excellent clinical results.
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Elmously A, Salemi A, Guy TS. Invited Commentary. Ann Thorac Surg 2018; 106:749. [PMID: 29758210 DOI: 10.1016/j.athoracsur.2018.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/16/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Adham Elmously
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - Arash Salemi
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - T Sloane Guy
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, 1300 York Ave, New York, NY 10065.
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