Multiple Valve Implantation Through a Minimally Invasive Approach: Comparison of Standard Median Sternotomy and Right Anterior Thoracotomy

Technique and early outcomes of total thoracoscopic double-valve replacement

Objective

Reports on aortic and mitral double-valve replacement through total thoracoscopy are scarce, with surgical techniques constantly evolving. We aimed to compare the feasibility and safety between total thoracoscopic double-valve replacement and median sternotomy double-valve replacement.

Methods

From November 2021 to March 2023, we performed double-valve replacements in 76 patients using the total thoracoscopic double-valve replacement. The control group comprised 77 patients who underwent median sternotomy double-valve replacement. We analyzed data on baseline characteristics, perioperative events, and early postoperative outcomes.

Results

In the total thoracoscopic double-valve replacement group, the cardiopulmonary bypass and aortic crossclamping times were 174.20 ± 38.87 minutes and 120.20 ± 19.54 minutes, respectively; both were significantly longer compared with those in the median sternotomy double-valve replacement group (cardiopulmonary bypass: 123.65 ± 15.33 minutes; aortic crossclamping: 82.86 ± 9.51 minutes, P < .001). The total thoracoscopic double-valve replacement group exhibited an extended operative duration, with a mean of 4.40 ± 0.76 hours, in contrast to 3.21 ± 0.68 hours in the median sternotomy double-valve replacement group (P < .001). Postoperatively, the total thoracoscopic double-valve replacement group demonstrated a significantly shorter mechanical ventilation duration (9.29 ± 3.12 hours) and reduced intensive care unit stay time (24.31 ± 7.29 hours) than the median sternotomy double-valve replacement group (11.49 ± 4.27 hours and 26.76 ± 5.89 hours, respectively; P values of .019 and .040, respectively). Furthermore, the total thoracoscopic double-valve replacement group experienced a shorter postoperative hospitalization time, averaging 6.21 ± 1.58 days, than the median sternotomy double-valve replacement group (8.35 ± 1.07 days, P < .001). The total thoracoscopic double-valve replacement group also exhibited significantly lower chest drainage volume (average 223.91 ± 53.93 mL) than the median sternotomy double-valve replacement group (382.56 ± 61.87 mL, P < .001). In terms of transfusion rates, the total thoracoscopic double-valve replacement group (9.21%) showed a marked reduction compared with the median sternotomy double-valve replacement group (36.36%, P < .001). Both groups had similar major complications.

Conclusions

The initial results of the total thoracoscopic double-valve replacement underscore its safety and efficacy. This approach extends the applicability of total thoracoscopic cardiac surgery and warrants deeper exploration.

Single or Combined Valve Surgery and Concomitant Right Coronary Artery Bypass through Right Anterior Minithoracotomy Approach

BACKGROUND

Patients with combined valve and coronary artery disease are commonly performed by standard median sternotomy approach for coronary artery bypass grafting (CABG) and valve surgery. The purpose of this study is to describe our experience and show feasibility and safety of minimally invasive approach to single or combined valve pathology with single-vessel right coronary artery (RCA) disease, even if it is suitable to percutaneous coronary intervention.

METHODS

This retrospective study comprised 28 consecutive patients who underwent single or combined valve surgery concomitant right CABG through right anterior minithoracotomy between February 2018 and December 2020. Preoperative evaluation, intraoperative, and postoperative outcomes were reviewed and analyzed.

RESULTS

There were 12 men and 16 women. The mean age was 71.46 ± 6.82 years. Ten patients were in New York Heart Association class III or IV. The mean cardiopulmonary bypass and aortic cross-clamping times were 117.6 ± 21.3 and 98.1 ± 22.6 minutes, respectively. The mean time to extubation was 9.7 ± 5.6 hours, the mean intensive care unit stay was 37.4 ± 14.6 hours, and the mean hospital stay was 6.9 ± 3.2 days. There was one patient who underwent reoperation for bleeding. There were no instances of postoperative stroke, myocardial infarction, renal failure, or wound infection. The mean follow-up was 19 ± 2.4 months.

CONCLUSION

Presence of RCA lesion is not a contraindication for minimally invasive approach in cases who underwent single or combined valve surgery. Combined valve surgery and right CABG via right anterior minithoracotomy are a safe and feasible option to standard median sternotomy surgery, even if RCA lesions seem suitable for stenting.

Minimal Access Aortic Valve Surgery

Minimally invasive approaches to the aortic valve have been described since 1993, with great hopes that they would become universal and facilitate day-case cardiac surgery. The literature has shown that these procedures can be undertaken with equivalent mortality rates, similar operative times, comparable costs, and some benefits regarding hospital length of stay. The competing efforts of transcatheter aortic valve implantation for these same outcomes have provided an excellent range of treatment options for patients from cardiology teams. We describe the current state of the art, including technical considerations, caveats, and complications of minimal access aortic surgery and predict future directions in this space.

Propensity-matched analysis of two port approach versus three port approach for totally thoracoscopic mitral valve replacement

BACKGROUND

To objectively evaluate the feasibility, safety, effectiveness and short-term outcome of totally thoracoscopic mitral valve replacement via two port approach, we conducted a retrospective study comparing two port approach with three port approach for mitral valve replacement.

METHODS

Data for all thoracoscopic mitral valve replacement were analyzed from Guangdong Cardiovascular Institute between January 1, 2016 and December 31, 2017. To account for selection bias between two port approach and three approach, one-to-one propensity score caliper matching without replacement was performed. The clinical data of the two groups were collected, including preoperative cardiac function, operative data, postoperative complications, and short-term outcome.

RESULTS

A total of 330 patients who underwent totally thoracoscopic mitral replacement via two port or three port from January 1, 2016 to December 31, 2017 were enrolled (two-port group: n=103; three-port group: n=227). Propensity score matching resulted in 71 matched pairs with improved balance post matching in baseline covariates. The baseline differences between two groups were eliminated (P>0.05 for all baseline variables). The cardiopulmonary bypass time (min) (154.27±57.02 vs. 142.68±51.33 P=0.183) and the aortic cross-clamp time (min) (106.99±106.98 vs. 90.16±31.63 P=0.206) in the two-port group were not significantly different from those in the three-port group. No significant difference was observed between the two groups in mechanical ventilation time, duration of intensive care unit stay, or amount of postoperative chest drainage. No perioperative death or re-exploration for bleeding was found in either group. As for other postoperative complications, two groups had the similar rate of lung infection lung infection (1.41% vs. 1.33% P=1.000) or acute renal failure (1.41% vs. 1.41% P=1.000).

CONCLUSIONS

No significant differences in cardiopulmonary bypass time, aortic cross-clamp time, overall operative time, perioperative mortality, or complications were observed between two-port and three-port totally thoracoscopic mitral valve replacement. Two-port totally thoracoscopic mitral valve replacement is a safe, effective, and feasible procedure for mitral valve replacement.