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Gregory AJ, Kent WDT, Adams C, Arora RC. Closing the care gap: combining enhanced recovery with minimally invasive valve surgery. Curr Opin Cardiol 2024; 39:380-387. [PMID: 38606679 DOI: 10.1097/hco.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Patients with advanced age and frailty require interventions for structural heart disease at an increasing rate. These patients typically experience higher rates of postoperative morbidity, mortality and prolonged hospital length of stay, loss of independence as well as associated increased costs to the healthcare system. Therefore, it is becoming critically important to raise awareness and develop strategies to improve clinical outcomes in the contemporary, high-risk patient population undergoing cardiacprocedures. RECENT FINDINGS Percutaneous options for structural heart disease have dramatically improved the therapeutic options for some older, frail, high-risk patients; however, others may still require cardiac surgery. Minimally invasive techniques can reduce some of the physiologic burden experienced by patients undergoing surgery and improve recovery. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) is a comprehensive, interdisciplinary, evidence-based approach to perioperative care. It has been shown to improve recovery and patient satisfaction while reducing complications and length of stay. SUMMARY Combining minimally invasive cardiac surgery with enhanced recovery protocols may result in improved patient outcomes for a patient population at high risk of morbidity and mortality following cardiac surgery.
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Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - William D T Kent
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Corey Adams
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Rakesh C Arora
- Harrington Heart and Vascular Institute - University Hospitals, Cleveland, Ohio, USA
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Elmously A, Lahan S, Al Abri Q, Wyler von Ballmoos MC, Ramchandani M. Sutureless Perceval Valve: Size Matters. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:311-315. [PMID: 37585809 DOI: 10.1177/15569845231190881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Adham Elmously
- Department of Cardiovascular Surgery, Houston Methodist Hospital, DeBakey Heart and Vascular Center, TX, USA
| | - Shubham Lahan
- Department of Cardiovascular Surgery, Houston Methodist Hospital, DeBakey Heart and Vascular Center, TX, USA
| | - Qasim Al Abri
- Department of Cardiac Surgery, National Heart Center, Royal Hospital, Muscat, Oman
| | | | - Mahesh Ramchandani
- Department of Cardiovascular Surgery, Houston Methodist Hospital, DeBakey Heart and Vascular Center, TX, USA
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Vohra HA, Salmasi MY, Mohamed F, Shehata M, Bahrami B, Caputo M, Deshpande R, Bapat V, Bahrami T, Birdi I, Zacharias J. Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting. Open Heart 2023; 10:e002194. [PMID: 37001910 PMCID: PMC10069572 DOI: 10.1136/openhrt-2022-002194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/27/2023] [Indexed: 04/04/2023] Open
Abstract
The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.
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Affiliation(s)
| | | | | | | | | | | | | | - Vinayak Bapat
- Cardiovascular Directorate, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Inderpaul Birdi
- Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Joseph Zacharias
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
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Geicu L, Busuttil O, D’Ostrevy N, Pernot M, Benali W, Labrousse L, Modine T. Updates on the Latest Surgical Approach of the Aortic Stenosis. J Clin Med 2021; 10:jcm10215140. [PMID: 34768660 PMCID: PMC8584939 DOI: 10.3390/jcm10215140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/16/2022] Open
Abstract
Over the last twenty years, we marked significant progresses in the field of tissue engineering and the development of new aortic valve structural and delivery systems. These continuous iterations on the field, have completely changed the surgical indications and approaches for AVR. Nowadays, therapeutic decisions are endorsed by international guidelines; however, new technical advances need a new integrated approach. The clinical scenarios issued from the interaction between the Guidelines and the newest approaches and technologies are regularly on debate by the Heart Team. We will present some of our most encountered situations and the pattern of our therapeutic decisions. To easily navigate through Guidelines and clinical scenarios, we reported in this review a simplified and easy to use Clinical decision-making algorithm that may be a valuable tool in our daily practice.
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Affiliation(s)
- Lucian Geicu
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal University, Montreal, QC H1T 1C8, Canada; (L.G.); (W.B.)
| | - Olivier Busuttil
- Unité Médico-Chirurgicale, Hôpital Haut Lévêque, CHU de Bordeaux, CEDEX, 33604 Pessac, France; (O.B.); (M.P.); (L.L.)
| | - Nicolas D’Ostrevy
- Cardiac Surgery Department, CHU de Clermont Ferrand, 63003 Clermont Ferrand, France;
| | - Mathieu Pernot
- Unité Médico-Chirurgicale, Hôpital Haut Lévêque, CHU de Bordeaux, CEDEX, 33604 Pessac, France; (O.B.); (M.P.); (L.L.)
| | - Walid Benali
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal University, Montreal, QC H1T 1C8, Canada; (L.G.); (W.B.)
| | - Louis Labrousse
- Unité Médico-Chirurgicale, Hôpital Haut Lévêque, CHU de Bordeaux, CEDEX, 33604 Pessac, France; (O.B.); (M.P.); (L.L.)
| | - Thomas Modine
- Unité Médico-Chirurgicale, Hôpital Haut Lévêque, CHU de Bordeaux, CEDEX, 33604 Pessac, France; (O.B.); (M.P.); (L.L.)
- Correspondence: ; Tel.: +33-05-5679-5697
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Jug J, Štor Z, Geršak B. Anatomical circumstances and aortic cross-clamp time in minimally invasive aortic valve replacement. Interact Cardiovasc Thorac Surg 2021; 32:204-212. [PMID: 33236100 DOI: 10.1093/icvts/ivaa251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/20/2020] [Accepted: 09/27/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Prolonged operative times, potentially leading to increased morbidity, are a possible drawback of minimally invasive aortic valve replacement. The aim of this study was to assess the impact of anatomical circumstances in the chest on aortic cross-clamp time. METHODS This retrospective study included 68 patients who underwent minimally invasive aortic valve replacement with the Perceval sutureless valve via right-anterior thoracotomy or with ministernotomy. Anatomical variables were measured during preoperative computer tomography scans. RESULTS Aortic cross-clamp time was shorter in those having ministernotomy than in the right-anterior thoracotomy group (41.1 vs 52.3 min; P < 0.001). Cardiopulmonary bypass (CPB) time was not significantly different between groups (P = 0.09). A multivariable linear-regression model (P = 0.018) showed the aortic dextroposition variable to be a significant predictor of the aortic cross-clamp method and CPB times (P = 0.005 and P = 0.003) independent of other anatomical variables in the right thoracotomy group (10 mm deviation from optimal position prolonged the times for 240 and 600 s). For the whole cohort, a correlation between aortic valve dimensions and operative times was found (P = 0.046, P = 0.009). A linear-regression model (P = 0.046) predicted 90 s longer aortic cross-clamp time and 231 s longer CPB time for every 1 mm smaller aortic valve diameter. CONCLUSIONS The anatomical variables are associated with the operative times in minimally invasive aortic valve replacement with sutureless valves. Considering this association, preplanning the procedure is recommended.
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Affiliation(s)
- Jure Jug
- Faculty of Medicine, Chair of Surgery, University of Ljubljana, Ljubljana, Slovenia
| | - Zdravko Štor
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Borut Geršak
- Faculty of Medicine, Chair of Surgery, University of Ljubljana, Ljubljana, Slovenia.,Nisteri, Medicine and Research, Ljubljana, Slovenia
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Lu F, Zhu SQ, Long X, Lin K, Qiu BQ, Pei X, Xu JJ, Wu YB. Clinical study of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision: The first Chinese experience. Asian J Surg 2021; 44:1063-1068. [PMID: 33622599 DOI: 10.1016/j.asjsur.2021.01.030] [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: 10/10/2020] [Revised: 12/01/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is an increasing demand for minimally invasive aortic valve replacement. This study aimed to investigate the safety and feasibility of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision. METHODS This was a retrospective study, and we collected information from 111 patients who underwent isolated aortic valve replacement surgery performed by the same surgeon from January 2018 to December 2019. According to the operative approach, the patients were divided into a sternotomy aortic valve replacement (SAVR) group (n = 62) and a minimally invasive aortic valve replacement (Mini-AVR) group (n = 49). We compared the intraoperative and postoperative data between the two groups. RESULT There was no difference in preoperative data between the Mini-AVR and SAVR. The postoperative ventilator-assisted time, CSICU time and postoperative hospital stay of the Mini-AVR were shorter than those of the SAVR [(15.45 ± 5.75) VS (18.51 ± 6.71) h; (1.77 ± 0.31) VS (2.04 ± 0.63) d; (8.69 ± 2.75) VS (10.77 ± 2.94) d], and the difference was statistically significant (P < 0.05). Mini-AVR had lower postoperative drainage and blood transfusion rates in the first 24 h than SAVR [(109.86 ± 125.98) VS (508.84 ± 311.70) ml; 22.4% VS 46.8%], and the differences were statistically significant (P < 0.05). The incidence of postoperative AF in the Mini-AVR group was also lower than that in the SAVR group (10.2% VS 30.6%), and the differences were statistically significant (P < 0.05). CONCLUSION Mini-AVR has the advantages of less ventilator time, a reduced need for blood transfusion, less AF and a faster recovery. Mini-AVR is a safe and feasible surgical technique that is worthy of clinical application.
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Affiliation(s)
- Feng Lu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Shu-Qiang Zhu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Xiang Long
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Kun Lin
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Bai-Quan Qiu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Xu Pei
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Jian-Jun Xu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Yong-Bing Wu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
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A Novel Computed Tomography Scan Tool for Patient Selection in Minithoracotomy Aortic Replacement. Ann Thorac Surg 2020; 110:e339-e341. [PMID: 32413359 DOI: 10.1016/j.athoracsur.2020.03.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/17/2020] [Accepted: 03/27/2020] [Indexed: 11/21/2022]
Abstract
Right anterior minithoracotomy is gaining larger acceptance for isolated aortic valve replacement. In some patients, however, surgical exposure during the intervention may be challenging even for experienced surgeons or centers. In our opinion, proper preoperative selection of the patients by computed tomography scan seems mandatory. We routinely perform right anterior minithoracotomy, and over time, we have found that the angle between the right border of the sternum and the left side of the aorta, at the level of the pulmonary artery, helps with patient selection.
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Kitamura H, Tamaki M, Kawaguchi Y, Okawa Y. Aortic Valve Replacement by a Transaxillary Anterior Minithoracotomy Approach. Ann Thorac Surg 2020; 110:e237-e239. [PMID: 32315645 DOI: 10.1016/j.athoracsur.2020.03.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
A modified transaxillary approach for aortic valve disease to obtain the same exposure as the anterior minithoracotomy approach and to preserve the pectoralis major muscle is presented. When the patient's right shoulder is adducted horizontally, or the right arm is flexed anteriorly 90 degrees and adducted to the left, the right axilla comes close to the chest midline. That means that a right anterior thoracotomy can be made through the right axilla when the arm position is adjusted appropriately. The modified new approach is safe and faster than the conventional transaxillary approach, and it provides cosmetic advantages to the patient.
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Affiliation(s)
- Hideki Kitamura
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan.
| | - Mototsugu Tamaki
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Yasuhiko Kawaguchi
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Yasuhide Okawa
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Aichi, Japan
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