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Ali A, Gray Z, Loor G, Shafii AE, Rosengart TK, Liao KK. Minimally Invasive Mitral Valve Surgery Using a Cold Fibrillatory Cardiac Arrest Technique in Patients With Prior Cardiac Surgery. Tex Heart Inst J 2024; 51:e238167. [PMID: 39028800 PMCID: PMC11258755 DOI: 10.14503/thij-23-8167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
OBJECTIVE Minimally invasive mitral valve surgery (mini-MVS) is typically reserved for patients who have not undergone open cardiac surgery. In the reoperative setting, using intrapericardial dissection for crossclamping the aorta through a minimally invasive approach can be difficult and, at times, risky. Cold fibrillatory cardiac arrest (CFCA) with systemic cardiopulmonary bypass without cross-clamping is a well-described technique; however, data about its safety for patients who undergo reoperative mini-MVS are limited. METHODS Data for 34 patients who underwent reoperative mini-MVS with CFCA from March 2017 to March 2022 were reviewed retrospectively. A mini right thoracotomy (n = 30) or robotic (n = 4) approach was used. Systemic hypothermia was induced to a target temperature of 25 °C. RESULTS Patient mean (SD) age was 64.5 (9.6) years, and 15 of 34 (44.1%) patients were women. Of those 34 patients, 23 (67.6%) had severe regurgitation, and 11 (32.4%) had severe stenosis. Before mini-MVS, 28 patients had undergone valve surgery, and 8 had undergone coronary artery bypass graft surgery. The mitral valve was repaired in 5 of 34 (14.7%) and replaced in 29 of 34 (85.3%) patients. No difference was observed in preoperative and postoperative left ventricular function (P = .82). In 1 patient, kidney failure developed that necessitated dialysis. No postoperative stroke or mortality at 30 days occurred. CONCLUSION Mini-MVS with CFCA is well tolerated in patients with prior cardiac surgery. Myocardial function was not impaired, nor was the risk of stroke increased in this cohort, indicating that CFCA is a safe alternative in this high-risk population.
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Affiliation(s)
- Ahmed Ali
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor St Luke's Hospital, Baylor College of Medicine, Houston, Texas
- Division of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Zachary Gray
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor St Luke's Hospital, Baylor College of Medicine, Houston, Texas
| | - Gabriel Loor
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor St Luke's Hospital, Baylor College of Medicine, Houston, Texas
- Division of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Alexis E. Shafii
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor St Luke's Hospital, Baylor College of Medicine, Houston, Texas
- Division of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Todd K. Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor St Luke's Hospital, Baylor College of Medicine, Houston, Texas
- Division of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Kenneth K. Liao
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor St Luke's Hospital, Baylor College of Medicine, Houston, Texas
- Division of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
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Tariq MA, Malik MK, Uddin QS, Altaf Z, Zafar M. Minimally Invasive Procedure versus Conventional Redo Sternotomy for Mitral Valve Surgery in Patients with Previous Cardiac Surgery: A Systematic Review and Meta-Analysis. J Chest Surg 2023; 56:374-386. [PMID: 37817430 PMCID: PMC10625962 DOI: 10.5090/jcs.23.038] [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: 03/20/2023] [Revised: 07/03/2023] [Accepted: 07/22/2023] [Indexed: 10/12/2023] Open
Abstract
Background The heightened morbidity and mortality associated with repeat cardiac surgery are well documented. Redo median sternotomy (MS) and minimally invasive valve surgery are options for patients with prior cardiac surgery who require mitral valve surgery (MVS). We conducted a systematic review and meta-analysis comparing the outcomes of redo MS and minimally invasive MVS (MIMVS) in this population. Methods We searched PubMed, EMBASE, and Scopus for studies comparing outcomes of redo MS and MIMVS for MVS. To calculate risk ratios (RRs) for binary outcomes and weighted mean differences (MDs) for continuous data, we employed a random-effects model. Results We included 12 retrospective observational studies, comprising 4157 participants (675 for MIMVS; 3482 for redo MS). Reductions in mortality (RR, 0.54; 95% confidence interval [CI], 0.37-0.80), length of hospital stay (MD, -4.23; 95% CI, -5.77 to -2.68), length of intensive care unit (ICU) stay (MD, -2.02; 95% CI, -3.17 to -0.88), and new-onset acute kidney injury (AKI) risk (odds ratio, 0.34; 95% CI, 0.19 to 0.61) were statistically significant and favored MIMVS (p<0.05). No significant differences were observed in aortic cross-clamp time, cardiopulmonary bypass time, or risk of perioperative stroke, new-onset atrial fibrillation, surgical site infection, or reoperation for bleeding (p>0.05). Conclusion The current literature, which primarily consists of retrospective comparisons, underscores certain benefits of MIMVS over redo MS. These include decreased mortality, shorter hospital and ICU stays, and reduced AKI risk. Given the lack of high-quality evidence, prospective randomized control trials with adequate power are necessary to investigate long-term outcomes.
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Affiliation(s)
- Muhammad Ali Tariq
- Department of Surgery, Dow University Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Minhail Khalid Malik
- Department of Surgery, Dow University Hospital, Dow University of Health Sciences, Karachi, Pakistan
| | - Qazi Shurjeel Uddin
- Department of Surgery, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Zahabia Altaf
- Department of Surgery, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Mariam Zafar
- Department of Surgery, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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Ökten EM, Özcan ZS, Arslanhan G, Şenay Ş, Güllü AÜ, Koçyiğit M, Değirmencioğlu A, Alhan C. Robotic-assisted mitral valve surgery without aortic cross-clamping: a safe and feasible technique. Front Cardiovasc Med 2023; 10:1111496. [PMID: 37324626 PMCID: PMC10264847 DOI: 10.3389/fcvm.2023.1111496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Background The primary objective of this study was to evaluate the safety and feasibility of robotic-assisted mitral valve surgery without aortic cross-clamping. Methods From January 2010 to September 2022, 28 patients underwent robotic-assisted mitral valve surgery without aortic cross-clamping in our center using DaVinci Robotic Systems. Clinical data during the perioperative period and early outcomes of the patients were recorded. Results Most patients were in New York Heart Association (NYHA) class II and III. Mean age and EuroScore II of the patients were 71.5 ± 13.5 and 8.4 ± 3.7 respectively. The patients underwent either mitral valve replacement (n = 16, 57.1%) or mitral valve repair (n = 12, 42.9%). Concomitant procedures were performed including tricuspid valve repair, tricuspid valve replacement, PFO closure, left atrial appendage ligation, left atrial appendage thrombectomy and cryoablation for atrial fibrillation. Mean CPB times were 140.9 ± 44.6 and mean fibrillatory arrest duration was 76.6 ± 18.4. Mean duration of ICU stay was 32.5 ± 28.8 h and mean duration of hospital stay 9.8 ± 8.3 days. One patient (3.6%) underwent revision due to bleeding. New onset renal failure was observed in one (3.6%) patient and postoperative stroke in one (3.6%) patient. Postoperative early mortality was observed in two (7.1%) patients. Conclusions Robotic-assisted mitral valve surgery without cross-clamping is a safe and feasible technique in high-risk patients undergoing redo mitral surgery with severe adhesions as well as in primary mitral valve cases that are complicated with ascending aortic calcification.
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Affiliation(s)
- Eyüp Murat Ökten
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Türkiye
| | - Zeynep Sıla Özcan
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Türkiye
| | - Gökhan Arslanhan
- Department of Cardiovascular Surgery, Acıbadem Maslak Hospital, Istanbul, Türkiye
| | - Şahin Şenay
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Türkiye
| | - Ahmet Ümit Güllü
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Türkiye
| | - Muharrem Koçyiğit
- Department of Anesthesiology, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Türkiye
| | - Aleks Değirmencioğlu
- Department of Cardiology, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Türkiye
| | - Cem Alhan
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Türkiye
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Shirke MM, Ravikumar N, Shawn TJX, Mutsonziwa N, Soh V, Harky A. Mitral valve surgery via repeat median sternotomy versus right mini-thoracotomy: A systematic review and meta-analysis of clinical outcomes. J Card Surg 2022; 37:4500-4509. [PMID: 36335611 DOI: 10.1111/jocs.17101] [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: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Redo mitral valve surgeries have high mortality and morbidity and can be physically demanding for patients. Median sternotomy remains the gold standard for most cardiac surgeries. To tackle certain risks with a re-sternotomy, alternative procedures such as the right anterolateral minithoracotomy have been explored. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini thoracotomy (MT) in mitral valve surgery. METHODS A systematic, electronic search was performed according to Preferred Reporting items for Systematic Reviews and Meta-analysis guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via a MS approach. RESULTS Twelve studies were identified, enrolling 4514 patients. Length of hospital stay(MD = -3.71, 95% confidence interval [CI] [-4.92, -2.49]), 30-day mortality(odds ratio [OR] = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure(OR = 0.38, 95% CI [0.22, 0.65]) were statistically significant in favor of the MT approach. Infection rates(OR = 0.56, 95% CI[0.25, 1.21]) and length of intensive care unit (ICU) stay (MD = -0.55, 95% CI[-1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time(MD = -2.33, 95% CI [-8.15, 3.50]), aortic cross-clamp time MD = -1.67, 95% CI[-17.07, 13.76]), and rates of stroke(OR = 1.03, 95% CI[0.55, 1.92]). CONCLUSION Right MT is a safe alternative to the traditional re-sternotomy for patients who have had previous cardiac surgery. The approach offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis. This review calls for robust trials in the field to further strengthen the evidence.
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Affiliation(s)
- Manasi Mahesh Shirke
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Nidhruv Ravikumar
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Tan Jia Xiang Shawn
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Nyasha Mutsonziwa
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Vernie Soh
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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Wisneski AD, Nguyen TC. Myocardial Protection in Minimally Invasive Cardiac Surgery: Evolved Techniques for the New Era of Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:88-91. [PMID: 35322712 DOI: 10.1177/15569845221082546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrew D Wisneski
- Division of Cardiothoracic Surgery, Department of Surgery, 8785University of California San Francisco, CA, USA
| | - Tom C Nguyen
- Division of Cardiothoracic Surgery, Department of Surgery, 8785University of California San Francisco, CA, USA
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Monsefi N, Makkawi B, Öztürk M, Alirezai H, Alaj E, Bakhtiary F. Right minithoracotomy and resternotomy approach in patients undergoing a redo mitral valve procedure. Interact Cardiovasc Thorac Surg 2022; 34:33-39. [PMID: 34999811 PMCID: PMC8743136 DOI: 10.1093/icvts/ivab228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/24/2021] [Accepted: 07/02/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES A minimally invasive approach via a thoracotomy is an alternative in challenging redo cardiac procedures. Our goal was to present our early postoperative experience with minimally invasive cardiac surgery via a right minithoracotomy (minimally invasive) and resternotomy in patients undergoing a mitral valve procedure as a reoperation. METHODS From 2017 until 2020, reoperation of the mitral valve was performed through a right-sided minithoracotomy in 27 patients and via a resternotomy in 26 patients. Patients with femoral vessels suitable for cannulation underwent a minimally invasive technique. Patients requiring concomitant procedures regarding the aortic valve were operated on via a resternotomy. RESULTS The mean age was 66 ± 12 years in the minimally invasive group and 65 ± 12 years in the whole cohort. The average Society of Thoracic Surgeons score was 11 ± 10% in the minimally invasive group and 13 ± 9% in all patients. The majority of the patients underwent reoperation because of severe mitral valve insufficiency (48% and 55%, respectively). The mean time to reoperation was 7 ± 9 years (minimally invasive group). The 30-day mortality was 4% in the minimally invasive group and 11% in the whole cohort. The blood loss was 566 ± 359 ml in the minimally invasive group and 793 ± 410 ml totally. There were no postoperative neurological complications in the minimally invasive group and 1 (2%) in the whole cohort. Postoperative echocardiography revealed competent mitral valve/prosthesis function in all patients. CONCLUSIONS A minimally invasive approach for a mitral valve reoperation in selected patients is a safe alternative to resternotomy with a low transfusion requirement. Both surgical techniques are associated with good postoperative outcomes.
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Affiliation(s)
- Nadejda Monsefi
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Basel Makkawi
- Department of Cardiac Surgery, Helios Heart Center Siegburg, Siegburg, Germany
| | - Mahmut Öztürk
- Department of Cardiac Surgery, Helios Heart Center Siegburg, Siegburg, Germany
| | - Hossien Alirezai
- Department of Cardiac Surgery, Helios Heart Center Siegburg, Siegburg, Germany
| | - Eissa Alaj
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
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Bakaeen FG, Ghandour H, Ravichandren K, Pettersson GSB, Weiss AJ, Tong MZY, Soltesz EG, Johnston DR, Houghtaling PL, Smedira NG, Roselli EE, Blackstone EH, Gillinov AM, Svensson LG. Risks and Outcomes of Reoperative Cardiac Surgery in Patients with Patent Bilateral Internal Thoracic Artery Grafts. Ann Thorac Surg 2021; 114:736-743. [PMID: 34597684 DOI: 10.1016/j.athoracsur.2021.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 07/08/2021] [Accepted: 08/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Reoperative cardiac surgery in patients with patent bilateral internal thoracic arteries (ITA) grafts is technically challenging. METHODS From 2008-2017, of 7,640 patients undergoing reoperative cardiac surgery, 116 (1.5%) had patent bilateral ITA grafts, including 28 with a right ITA crossing the midline. Mean age was 70±9.6 years, and 111 patients (96%) were male. Reoperations included isolated coronary artery bypass grafting (CABG; n=11), isolated valve (n=55), valve+CABG (n=26), and other procedures (n=24). Clinical details, intraoperative management, and perioperative outcomes were analyzed. RESULTS Aortic cannulation was central in 64 patients (56%) and via femoral or axillary artery in 50 (44%). Four patients (3.4%) had planned transection and reattachment of ITAs crossing the midline, and 4 (3.4%) had ITA injuries, all right ITAs, 3 crossing the midline; 3 were repaired with an interposition vein graft, and 1 was managed by translocating the right ITA as a Y-graft off another graft. Patent ITAs were managed by atraumatic occlusion during aortic clamping in 90 patients (78%) and by systemic cooling without ITA occlusion in 19. There were 6 operative deaths, all due to low cardiac output syndrome (5.2%), 4 strokes (3.4%), and 5 cases of new postoperative dialysis (4.3%). CONCLUSIONS Risk of injury to bilateral ITA grafts during reoperation is high, and right ITAs crossing the midline present a particular risk of injury and should inform planning for primary CABG. Risk of low cardiac output syndrome underscores the challenge of ensuring adequate myocardial protection.
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Affiliation(s)
- Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute.
| | - Hiba Ghandour
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Kirthi Ravichandren
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Go Sta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Aaron J Weiss
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | | | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute
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Ko K, de Kroon TL, Kelder JC, Saouti N, van Putte BP. Reoperative Mitral Valve Surgery Through Port Access. Semin Thorac Cardiovasc Surg 2021; 34:1208-1217. [PMID: 34425218 DOI: 10.1053/j.semtcvs.2021.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/13/2021] [Indexed: 11/11/2022]
Abstract
Minimally invasive mitral valve surgery (MIMVS) has become the standard approach for mitral valve pathology in many centres. The anterolateral mini thoracotomy access is beneficial in reoperative surgery by avoiding repeat sternotomy associated risks. The aim of this study is to analyse the safety of this technique. All patients undergoing reoperative MIMVS between 2008 and 2019 were studied retrospectively. Primary endpoint was 30-day major complications and mortality; secondary outcome was long term survival, reoperation rate and rate of more than moderate recurrent regurgitation. 146 Patients underwent reoperative MIMVS with a mean age of 68 ± 8 years. The composite outcome of 30-day major complication and mortality was 29.5%. 30-Day mortality was 6.2% and stroke rate 3.4%. Survival for the whole cohort was 89.7 ± 2.5% at 1-year, 71.6 ± 4.3% at 5 year and 50.9 ± 5.9% at 8-year follow up. Cox regression analysis revealed reduced left ventricular function (HR 2.8; 95%CI 1.5 - 5.0), GFR < 60 (HR 2.1; 95%CI 1.2 - 3.7) and active endocarditis (HR 6.4; 95%CI 2.7 - 15.4) as variables associated with reduced long-term survival. The cumulative incidence of re-operation after mitral valve replacement was 11.3 ± 3.2% at 5-year and for repair 16.2 ± 7.5% at 5-year. The cumulative incidence of more than moderate recurrent regurgitation after mitral valve repair was 25.4 ± 9.0% at 3-year. Minimally invasive access in reoperative mitral valve surgery in the current study showed similar 30-day mortality and stroke rate compared to repeat sternotomy results reported in literature.
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Affiliation(s)
- Kinsing Ko
- Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands; Cardiothoracic Surgery, Radboud UMC, Nijmegen, The Netherlands.
| | - Thom L de Kroon
- Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Nabil Saouti
- Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands; Cardiothoracic Surgery, Amphia Hospital, Breda, The Netherlands
| | - Bart P van Putte
- Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands; Cardiothoracic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
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Chi NH, Fu HY, Yu HY, Wu IH, Wang CH, Chou NK. Comparison of robotic and conventional sternotomy in redo mitral valve surgery. J Formos Med Assoc 2021; 121:395-401. [PMID: 34120802 DOI: 10.1016/j.jfma.2021.05.023] [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: 10/27/2020] [Revised: 04/22/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/PURPOSE Redo operation for mitral valve surgery carries higher risks than first time cardiac surgery. The adhesion between sternum and heart, and also the complexity of second time operation make the redo operation more difficult. The robotic surgery carries some benefit in terms of magnification, assisted by the scope view and precise movement of the instruments. We compared the results of our robotic redo mitral valve surgeries with those of conventional re-sternotomy. METHODS Medical records of patients who underwent redo mitral valve surgeries between 2012 and 2019 at our hospital were retrospectively analyzed. Demographic data, patients' medical histories, presenting symptoms, image analyses, echocardiogram data, operative procedures and postoperative clinical outcomes were collected through chart review. RESULTS A total of 67 redo mitral valve surgeries, including 23 robotic and 44 re-sternotomy procedures were performed. There were no differences in age, previous operation times, and intervals to previous surgery. Comorbidities of both groups were similar. There was no surgical mortality in the robotic group, and it was 9.0% in the re-sternotomy group (p = 0.287). Operation time was shorter in the robotic group (176 vs. 321 min; robotic vs. re-sternotomy, p=0.0279). Blood transfusion was lower in the robotic group (1 vs. 2 units; robotic vs. re-sternotomy, p = 0.01189). The ventilation time, ICU stay time, and recheck bleeding rate were similar in both groups. CONCLUSIONS In select patients, robotic redo mitral valve surgery is safe and feasible. It could offer low operative mortality. It is associated with shorter operative times, than re-sternotomy and provides equal immediate operative results.
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Affiliation(s)
- Nai-Hsin Chi
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsun-Yi Fu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsi-Yu Yu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Hui Wu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Hsien Wang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Nai-Kuan Chou
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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10
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Hussain A, Chacko J, Uzzaman M, Hamid O, Butt S, Zakai SB, Khan H. Minimally invasive (mini-thoracotomy) versus median sternotomy in redo mitral valve surgery: A meta-analysis of observational studies. Asian Cardiovasc Thorac Ann 2021; 29:893-902. [PMID: 33611952 DOI: 10.1177/0218492321997084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Redo mitral valve surgery has traditionally been performed via a median sternotomy. It is often challenging and is associated with increased perioperative mortality. Advances in cardiac surgical techniques over the last two decades have led to an increase in the use of a minimally invasive approach via a right anterolateral mini-thoracotomy as opposed to a repeat median sternotomy. However, despite these advances, there is no general consensus on the best form of entry, and as of yet, there are no randomized controlled trials. We performed a meta-analysis of observational studies to aid in determining the best approach for redo mitral valve surgery. METHOD The MEDLINE and EMBASE databases were conducted up until 1 June 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random effects modelling and the I2-test for heterogeneity. Seven retrospective observational studies were included, enrolling a total of 1070 patients. RESULTS There were a total of 1070 patients. Of these 364 had non-sternotomy approach compared with 707 patients who had median sternotomy. Further subgroup analysis revealed that 327 of the 364 patients had a mini-thoracotomy approach while the remaining 37 patients had a full thoracotomy approach. In-hospital mortality and length of stay were less in non-sternotomy group compared to median sternotomy group. There were no differences in stroke, CPB time and wound infections between the two groups. CONCLUSION Redo mitral valve surgery can be performed safely with satisfactory outcomes via a mini-thoracotomy approach. This meta-analysis shows comparable results with reduced in-hospital mortality and hospital length of stay with a mini-thoracotomy approach.
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Affiliation(s)
- Azhar Hussain
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Jacob Chacko
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Mohsin Uzzaman
- Department of Cardiac Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Osama Hamid
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Salman Butt
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Saad Badar Zakai
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Habib Khan
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
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11
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Kindzelski BA, Bakaeen FG, Tong MZ, Roselli EE, Soltesz EG, Johnston DR, Wierup P, Pettersson GB, Houghtaling PL, Blackstone EH, Gillinov AM, Svensson LG. Modern practice and outcomes of reoperative cardiac surgery. J Thorac Cardiovasc Surg 2021; 164:1755-1766.e16. [PMID: 33757681 DOI: 10.1016/j.jtcvs.2021.01.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest. METHODS From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect. RESULTS Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2). CONCLUSIONS Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.
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Affiliation(s)
- Bogdan A Kindzelski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Per Wierup
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Three-dimensional Video Assistance Improves Early Results in Minimally Invasive Mitral Valve Surgery. ASAIO J 2020; 67:769-775. [PMID: 33315660 DOI: 10.1097/mat.0000000000001326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Compared with the mid-sternotomy approach, minimally invasive mitral valve surgery is usually associated with longer surgical times. The increasing use of new technology has facilitated this procedure and shortened its duration, which may further improve surgical results. Since 2004, 152 patients have undergone minimally invasive mitral valve repair. Video-assisted 2D technology was used for the first 112 patients, while video-assisted 3D technology was used for the remaining 40 patients. All patients were divided into three groups: group 1 - the first 50 patients (learning curve using 2D technology); group 2 - 62 patients (past the learning curve using 2D technology); and group 3 - 40 patients (3D technology). Mean patient age was 50 ± 12 years. There was no in-hospital mortality and no conversions to mid-sternotomy. Cardiopulmonary bypass and cross-clamp times were significantly shorter in group 3 compared with groups 2 and 1, respectively (108 ± 19 vs. 124 ± 22 vs. 139 ± 27, p < 0.001; and 76 ± 14 vs. 86 ± 18 vs. 97 ± 18, p < 0.001). Intraoperative echocardiography revealed higher freedom from more than mild residual mitral regurgitation after the first pump-run in group 3 compared to group 2 (97.5% vs. 90.3%, p = 0.04). Patients in the 3D group had less postoperative bleeding (p = 0.026) and a higher glomerular filtration rate before discharge (p < 0.001) compared with the 2D groups. No significant differences were observed in ventilation time (p = 0.066) and intensive care unit duration (p = 0.071). We concluded that in minimally invasive mitral valve repair, 3D video-assisted technology may provide shorter surgical times compared to 2D video-assisted technology.
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Güllü AÜ, Şenay Ş, Ersin E, Demirhisar Ö, Whitham T, Koçyiğit M, Alhan C. Robotic-assisted cardiac surgery without aortic cross-clamping: A safe alternative approach. J Card Surg 2020; 36:165-168. [PMID: 33135200 DOI: 10.1111/jocs.15160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Attempting to place an aortic cross-clamp may complicate surgery and postoperative outcomes in patients who have mediastinal adhesions or in those with extensive aortic calcification. Although right-sided cardiac surgery via thoracotomy is not a new technique in these patients, robotic-assisted intracardiac repair without cross-clamping was not reported in a large group of patients previously. In this study, the safety of robotic-assisted cardiac surgery without aortic cross-clamping was examined. METHODS From January 2010 to March 2020, 304 patients underwent robotic-assisted cardiac surgery in our center and in 25 of these patients (8.2%) with a mean age of 65.5 ± 20 years myocardial protection was succeeded with moderate hypothermic ventricular fibrillatory arrest. Severe pericardial adhesions or existence of highly calcified ascending aorta were the indications for fibrillatory arrest during robotic assistant surgery. RESULTS Most patients were in New York Heart Association Class ≥II (88.0%) and the mean logistic Euroscore value was 18.5 ± 22.3. The type of operations were mitral/tricuspid valve repair/replacement, cryoablation, atrial septal defect closure, and pericardiectomy. Cardiopulmonary bypass times were 141.5 ± 47 (minimum 77-maximum 252) min. There was no case of conversion to open thoracotomy or sternotomy. Hemiparesis was observed in one patient. Two patients with 78.2 and 81.9 Euroscore values had mesenteric ischemia and multiorgan failure, respectively, and died at postoperative period. CONCLUSIONS Robotic-assisted cardiac surgery without cross-clamping may provide reasonable outcomes in patients with severe aortic calcification or mediastinal adhesions undergoing intracardiac repair. These acceptable outcomes may encourage surgeons to perform this approach in appropriate group of patients.
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Affiliation(s)
- Ahmet Ümit Güllü
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Şahin Şenay
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Egemen Ersin
- Programme of Perfusion, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Önder Demirhisar
- Programme of Perfusion, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Tarik Whitham
- Department of Biology, College of Arts and Sciences, Ohio State University, Columbus, Ohio, USA
| | - Muharrem Koçyiğit
- Department of Anesthesiology, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Cem Alhan
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
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Right mini-thoracotomy approach in patients undergoing redo mitral valve procedure. Indian J Thorac Cardiovasc Surg 2020; 36:591-597. [PMID: 33100620 DOI: 10.1007/s12055-020-01027-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/22/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022] Open
Abstract
Aim A minimally invasive technique is an attractive option in cardiac surgery. In this study, we present our experience with minimally invasive cardiac surgery (MICS) via right mini-thoracotomy on patients undergoing mitral valve procedure as reoperation. Methods From 2017 until 2019, 20 patients underwent reoperation of the mitral valve through a right-sided mini-thoracotomy. Cardiopulmonary bypass was established through cannulation of the femoral vessels. All patients requiring isolated re-operative mitral valve surgery with suitable femoral vessels for cannulation were included in the study. Patients requiring concomitant coronary artery bypass grafting (CABG) or with peripheral artery disease were excluded. Results The mean age was 65 ± 12 years. The average log. EuroSCORE was 9 ± 5%. Ten patients with severe mitral valve regurgitation (MR) underwent re-repair of the mitral valve. Seven of them were post mitral valve repair (MVR), one was post aortic valve replacement (AVR), one had tricuspid valve repair, and one other patient had CABG before. Ten patients underwent mitral valve replacement due to mixed mitral valve disease (n = 9) or mitral valve endocarditis (n = 1). Eight patients were post MVR and 2 had AVR before. The mean time to reoperation was 7.5 ± 8 years. In-hospital mortality was 5% (n = 1). The mean cross clamp time was 54 ± 26 min. Postoperative echocardiography revealed competent valve function in all cases with mean ejection fraction of 55 ± 9%. The Kaplan-Meier 1- and 2-year survival was 95%. Conclusion The MICS approach for mitral valve reoperation in selected patients seems to be safe and feasible. It is also a surgical option for high-risk patients.
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Saisho H, Tobinaga S, Yoshida S, Tanaka H. Surgical repair of Stanford type A acute aortic dissection with extreme tuberculosis-related mediastinal deviation. Interact Cardiovasc Thorac Surg 2019; 29:800-802. [PMID: 31369121 DOI: 10.1093/icvts/ivz172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/12/2019] [Accepted: 06/23/2019] [Indexed: 11/13/2022] Open
Abstract
In this article, we report on the case of an 85-year-old woman with a history of left pulmonary tuberculosis, who was referred for Stanford type A acute aortic dissection. A preoperative chest X-ray and computed tomography revealed extreme mediastinal deviation to the left. We decided to perform surgery with left rib-cross thoracotomy. This approach yielded excellent exposure of the aortic root, ascending aorta and aortic arch. Following an uneventful operative and postoperative course, the patient was discharged on the 21st postoperative day.
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Affiliation(s)
- Hiroyuki Saisho
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Satoru Tobinaga
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Shohei Yoshida
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Hiroyuki Tanaka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
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Wang Q, Xue X, Yang J, Yang Q, Wang P, Wang L, Zhang P, Wang S, Wang J, Xu J, Xiao J, Wang Z. Right mini-thoracotomy approach reduces hospital stay and transfusion of mitral or tricuspid valve reoperation with non-inferior efficacy: evidence from propensity-matched study. J Thorac Dis 2018; 10:4789-4800. [PMID: 30233851 DOI: 10.21037/jtd.2018.07.53] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background There is limited evidence about the efficacy and cost difference between minimally invasive and conventional valve reoperation. This study intended to compare the short-term efficacy and cost between right mini-thoracotomy approach and median sternotomy approach in valve reoperation. Methods From Feb 2011 to Sep 2017, 156 patients underwent valve reoperation including 68 cases of minimally invasive approach and 88 cases of traditional median sternotomy approach in our hospital. A propensity scoring was used to match patients with similar demographic characteristics. A total of 42 pairs of patients were left and divided into the conventional sternotomy group (CS group) and the right mini-thoracotomy group (RT group). A retrospective study of efficacy and cost was conducted between two groups. Results There was no statistical difference between two groups in demographical characteristics after propensity-scoring match (P>0.05). In-hospital mortality was 11.9% (5/42) for CS group and 7.1% (3/42) for the RT group (P=0.687). No significant disparity was found in the incidence of complications between two groups (P>0.05). CPB time (P=0.012), bypass time (P=0.006) and operation time (P=0.003) of CS group were significantly higher than RT group. Blood loss (P=0.014) and transfusion volume (P=0.003) of RT group was less than CS group. Shorter ICU and hospital stay was seen in RT group compared with CS group (P<0.001). Though the materials cost of RT group was higher than CS group (P<0.001), no significant disparity was found in total cost between CS group and RT group (P=0.790). Conclusions The right mini-thoracotomy approach can achieve equivalent efficacy with conventional median approach, and doesn't necessarily increase the total cost. Moreover, the minimally invasive approach can decrease the operation time, hospital stay and blood product transfusion.
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Affiliation(s)
- Qing Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Xiaofei Xue
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Jie Yang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Qian Yang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Pei Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Liaoyuan Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Suyu Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Jing Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Jibin Xu
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Jian Xiao
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Zhinong Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
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Minol JP, Akhyari P, Boeken U, Albert A, Rellecke P, Dimitrova V, Sixt SU, Kamiya H, Lichtenberg A. Previous Sternotomy as a Risk Factor in Minimally Invasive Mitral Valve Surgery. Front Surg 2018; 5:5. [PMID: 29479532 PMCID: PMC5811546 DOI: 10.3389/fsurg.2018.00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 01/15/2018] [Indexed: 11/13/2022] Open
Abstract
Background Cardiac redo surgery, especially after a full sternotomy, is considered a high-risk procedure. Minimally invasive mitral valve surgery (MIMVS) is a potential therapeutic approach. However, current developments in interventional cardiology necessitate additional discussion regarding the therapy of choice in high-risk patients. In this context, it is necessary to clarify the perioperative and postoperative risks induced by the factor previous sternotomy in the setting of MIMVS. Thus, we present a comparative study analyzing the outcome of MIMVS after previous sternotomy vs. primary operation. Methods We identified 19 patients who received isolated or combined mitral valve (MV) surgery via the MIMVS approach after previous full sternotomy (PS group) and compared the results to those of a group of 357 patients who received primary MIMVS (non-PS group). After a propensity score analysis, groups of n = 15 and n = 131, respectively, were subjected to a comparative evaluation. A 1-year follow-up analysis of functional cardiac parameters and clinical symptoms was performed, accompanied by a Kaplan-Meier analysis. Results Except for the rate of realized MV reconstructions (PS group: 53.8% vs. non-PS group: 85.5%; p = 0.011), no significant differences were to be noted within the intraoperative and early postoperative course. However, patients in the PS group experienced an increased intensive care unit stay length (PS group: 2 days, 95% CI, 1-8 vs. non-PS group: 1 day, 95% CI, 1-2; p = 0.072). The follow-up examinations revealed excellent functional and clinical outcomes for both groups. The Kaplan-Meier analysis displayed no significant difference regarding the postoperative mortality (p = 0.929) related to the patients at risk. Conclusion A previous sternotomy remains a risk factor for MIMVS and demands special attention in the early postoperative period. Nevertheless, the early- and late-term results concerning the functional and clinical outcomes suggest that the MIMVS procedure is satisfactory, even after a full sternotomy.
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Affiliation(s)
- Jan-Philipp Minol
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Alexander Albert
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Philipp Rellecke
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Vanessa Dimitrova
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Stephan Urs Sixt
- Department of Anaesthesiology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Hiroyuki Kamiya
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
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Ghoneim A, Bouhout I, Mazine A, Fortin W, El-Hamamsy I, Jeanmart H, Pellerin M, Bouchard D. Beating Heart Minimally Invasive Mitral Valve Surgery in Patients With Patent Coronary Bypass Grafts. Can J Cardiol 2016; 32:987.e1-6. [DOI: 10.1016/j.cjca.2015.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/30/2015] [Accepted: 09/23/2015] [Indexed: 11/25/2022] Open
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Barbero C, Marchetto G, Ricci D, El Qarra S, Attisani M, Filippini C, Boffini M, Rinaldi M. Right Minithoracotomy for Mitral Valve Surgery: Impact of Tailored Strategies on Early Outcome. Ann Thorac Surg 2016; 102:1989-1994. [PMID: 27435516 DOI: 10.1016/j.athoracsur.2016.04.104] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 04/21/2016] [Accepted: 04/28/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Interest in right minithoracotomy mitral valve surgery (MVS) is rapidly growing and, to date, different perfusion strategies and aortic clamping techniques are available. However each approach carries specific advantages and drawbacks. This retrospective study analyses our experience in right minithoracotomy MVS with different arterial perfusion and aortic clamping strategies, highlighting the results of a patient tailored approach. METHODS Between March 2009 and March 2014, 460 patients with a full preoperative work-up that included also aortoiliac-femoral axis' screening underwent right minithoracotomy MVS. One hundred and eight were redo cases (23.5%), 63 had aortoiliac atheromatous disease or significant tortuosity (13.7%), and 38 had chronic obstructive pulmonary disease (8.3%). Based on anatomy and comorbidities, each patient was allocated to the most appropriate of 3 approaches: femoral arterial cannulation with endoaortic balloon (P+EB) (247, 53.7%) or with transthoracic clamp (P+XC) (150, 32.6%), and direct aortic cannulation with endoaortic balloon occlusion (C+EB) (63, 13.7%). RESULTS No cases of aortic dissection were reported. Early outcome were similar between the 3 groups; no differences were reported in terms of stroke rate (1.7% in the P+EB, 2% in the P+XC, and no cases in the C+EB group; p = NS) and 30-day mortality (2.1% in the P+EB, 2.7% in the P+XC, and 1.6% in the C+EB group; p = NS). Logistic regression showed no influences of arterial perfusion and aortic clamping techniques on 30-day mortality and stroke. CONCLUSIONS Right minithoracotomy MVS can routinely be performed with favorable outcomes in all comers when perfusion strategies and clamping techniques are carefully selected after proper evaluation of the patient's preoperative characteristics.
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Affiliation(s)
- Cristina Barbero
- Department of Cardiovascular and Thoracic Surgery, University of Turin, Torino, Italy.
| | - Giovanni Marchetto
- Department of Cardiovascular and Thoracic Surgery, University of Turin, Torino, Italy
| | - Davide Ricci
- Department of Cardiovascular and Thoracic Surgery, University of Turin, Torino, Italy
| | - Suad El Qarra
- Department of Cardiovascular and Thoracic Surgery, University of Turin, Torino, Italy
| | - Matteo Attisani
- Department of Cardiovascular and Thoracic Surgery, University of Turin, Torino, Italy
| | - Claudia Filippini
- Department of Anesthesia and Critical Care, University of Turin, Torino, Italy
| | - Massimo Boffini
- Department of Cardiovascular and Thoracic Surgery, University of Turin, Torino, Italy
| | - Mauro Rinaldi
- Department of Cardiovascular and Thoracic Surgery, University of Turin, Torino, Italy
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Tang P, Onaitis M, Gaca JG, Milano CA, Stafford-Smith M, Glower D. Right Minithoracotomy Versus Median Sternotomy for Mitral Valve Surgery: A Propensity Matched Study. Ann Thorac Surg 2015; 100:575-81. [DOI: 10.1016/j.athoracsur.2015.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 03/29/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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Vallabhajosyula P, Wallen T, Pulsipher A, Pitkin E, Solometo LP, Musthaq S, Fox J, Acker M, Hargrove WC. Minimally Invasive Port Access Approach for Reoperations on the Mitral Valve. Ann Thorac Surg 2015; 100:68-73. [DOI: 10.1016/j.athoracsur.2015.02.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 02/04/2015] [Accepted: 02/12/2015] [Indexed: 11/15/2022]
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Kızıltan HT, İdem A, Salihi S, Demir AS, Korkmaz AA, Güden M. Mitral valve surgery using video-assisted right minithoracotomy and deep hypothermic perfusion in patients with previous cardiac operations. J Cardiothorac Surg 2015; 10:55. [PMID: 25880682 PMCID: PMC4419402 DOI: 10.1186/s13019-015-0259-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 04/01/2015] [Indexed: 11/17/2022] Open
Abstract
Background Redo-sternotomy for mitral valve (MV) surgery may be complex and attendant complications can be avoided using anterolateral right thoracotomy, deep hypothermia (20°C, nasopharyngeal) with low flow cardiopulmonary perfusion. Video-assisted minithoracotomy technique is a further improvement. Methods We performed 20 consecutive MV operations in patients with previous cardiac surgery using video-assisted right minithoracotomy, femoro-femoral bypass, deep hypothermia, low flow cardiopulmonary bypass without aortic cross-clamping. The mean follow-up was 30 ± 17.8 mo. Data is presented as the mean ± standard deviation of the mean. Results There were 11 males and 9 females (age, 62.3 ± 12.1; ejection fraction 50.1 ± 11.2). Operations included MV replacement (n = 11), MV repair (n = 5), and MV re-replacement (n = 4). There were no hospital deaths, and the mean hospital stay was 8 ± 2.9 days. There were no postoperative strokes or need for mechanical circulatory support. The mean cardiopulmonary bypass time was 152 ± 28 minutes. Two patients (10%) required inotropic support beyond 24 hrs. All patients were free from inotropic support at 48 hours. The mean number of transfused red cell units was 2.8 ± 0.8 (range, 2 to 4). One patient died in another institution six months postoperatively following surgery for acute type III aortic dissection. At 30 ± 17.8 months follow-up all patients were found to be in NYHA Class I or II. Conclusions Minimally invasive video-assisted MV surgery using deep hypothermia, low-flow cardiopulmonary bypass without aortic clamping can result in excellent clinical outcomes in patients with previous cardiac surgery via a median sternotomy. This technique offers reproducible results, good myocardial protection (as evidenced by the low rate of inotropic support that patients needed postoperatively), and low rates of complications.
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Affiliation(s)
- H Tarık Kızıltan
- Cardiovascular Surgery, Özel Adana Hastanesi, Hekimköy Sitesi Sarıçam D-5 No:108, 01000, Adana, Turkey.
| | - Aslı İdem
- Anesthesiology and Reanimation, Özel Adana Hastanesi, Adana, Turkey.
| | - Salih Salihi
- Cardiovascular Surgery, Fatih University, Medical Faculty, Istanbul, Turkey.
| | - Ali Soner Demir
- Cardiology, Fatih University, Medical Faculty, İstanbul, Turkey.
| | - Aşkın Ali Korkmaz
- Cardiovascular Surgery, Fatih University, Medical Faculty, Istanbul, Turkey.
| | - Mustafa Güden
- Cardiovascular Surgery, Fatih University, Medical Faculty, Istanbul, Turkey.
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Murzi M, Miceli A, Di Stefano G, Cerillo AG, Farneti P, Solinas M, Glauber M. Minimally invasive right thoracotomy approach for mitral valve surgery in patients with previous sternotomy: A single institution experience with 173 patients. J Thorac Cardiovasc Surg 2014; 148:2763-8. [DOI: 10.1016/j.jtcvs.2014.07.108] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 07/26/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022]
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Imran Hamid U, Digney R, Soo L, Leung S, Graham AN. Incidence and outcome of re-entry injury in redo cardiac surgery: benefits of preoperative planning. Eur J Cardiothorac Surg 2014; 47:819-23. [DOI: 10.1093/ejcts/ezu261] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 05/26/2014] [Indexed: 12/22/2022] Open
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Mandal K, Alwair H, Nifong WL, Chitwood WR. Robotically assisted minimally invasive mitral valve surgery. J Thorac Dis 2014; 5 Suppl 6:S694-703. [PMID: 24251030 DOI: 10.3978/j.issn.2072-1439.2013.11.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 11/02/2013] [Indexed: 11/14/2022]
Abstract
Increased recognition of advantages, over the last decade, of minimizing surgical trauma by operating through smaller incisions and its direct impact on reduced postoperative pain, quicker recovery, improved cosmesis and earlier return to work has spurred the minimally invasive cardiac surgical revolution. This transition began in the early 1990s with advancements in endoscopic instruments, video & fiberoptic technology and improvements in perfusion systems for establishing cardiopulmonary bypass (CPB) via peripheral cannulation. Society of Thoracic Surgeons data documents that 20% of all mitral valve surgeries are performed using minimally invasive techniques, with half being robotically assisted. This article reviews the current status of robotically assisted mitral valve surgery, its advantages and technical modifications for optimizing clinical outcomes.
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Affiliation(s)
- Kaushik Mandal
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore MD 21287, USA; ; Department of Cardiovascular Surgery, East Carolina Heart Institute at East Carolina University, Greenville NC 27834, USA
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Vallabhajosyula P, Wallen TJ, Solometo LP, Fox J, Vernick WJ, Hargrove WC. Minimally invasive mitral valve surgery utilizing heart port technology. J Card Surg 2014; 29:343-8. [PMID: 24495015 DOI: 10.1111/jocs.12293] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine operative outcomes of right mini-thoracotomy mitral valve surgery utilizing port access technology in first-time and reoperative cardiac surgery patients. METHODS From 2002 to 2011, 881 patients underwent minimally invasive mitral valve surgery. Of these, 154 patients had previous cardiac operations via sternotomy (Group 1), of which 18 (12%) had two previous operations. Seven hundred and twenty-seven patients had no previous cardiac operations (Group 2). RESULTS Patient demographics were similar in both groups. In Group 1, 76 (49%) patients had previous coronary artery bypass grafting, 13 (8%) had previous aortic valve surgery, and 57 (37%) had previous mitral valve surgery. Preoperative echo findings for Groups 1 and 2 included severe mitral regurgitation (MR) (88%, n = 135; 94%, n = 687), mitral stenosis (MS) (4%, n = 6; 2%, n = 12), MS + MR (8%, n = 13; 4%, n = 28), and ejection fraction (48%, 56%). Operative procedures in Groups 1 and 2 were MV repair (54%, n = 84; 89%, n = 645) and MV replacement (46%, n = 70; 11%, n = 82). Circulatory management techniques for Groups 1 and 2 included endoballoon (75%, n = 116; 79%, n = 576), Chitwood clamp (8%, n = 12; 20%, n = 147), and fibrillatory arrest (17%, n = 30; 0.5%, n = 4). Perioperative outcomes were: stroke: 2.5%, 1.6%; reoperation for bleeding: 5%, 6%; valvular reoperation rate: 0.6%, 2%; aortic dissection: 2.5%, 1%; and wound infection: 0%, 0%. Transfusion requirement was 49% (n = 76) and 31% (n = 232), respectively. Median hospital stay was seven and seven days, respectively. On postoperative echocardiography, 98% (n = 151) and 99% (n = 718) of patients had zero or trace MR (1+) with 100% freedom from MR > 2+. In-hospital mortality was 3% (n = 5) and 1% (n = 8). CONCLUSIONS Operative outcomes with minimally invasive mitral valve surgery utilizing port access technology can be performed safely. Stroke rate was higher in the reoperative cases (p = NS) although similar to reports evaluating redo sternotomy in mitral valve cases.
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Garbade J, Davierwala P, Seeburger J, Pfannmueller B, Misfeld M, Borger MA, Mohr FW. Myocardial protection during minimally invasive mitral valve surgery: strategies and cardioplegic solutions. Ann Cardiothorac Surg 2013; 2:803-8. [PMID: 24349985 DOI: 10.3978/j.issn.2225-319x.2013.09.04] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 09/06/2013] [Indexed: 12/13/2022]
Abstract
Effective myocardial protection and perfusion strategies during minimally invasive mitral valve surgery (Mini-MV) have evolved over the last decade. Our institutional approach for right-sided Mini-MV has been standardized over the last 15 years in more than 4,500 cases. Cardiopulmonary bypass (CPB) is usually instituted by right-sided femoral arterial and venous cannulation with additional cannulation of the right jugular vein in patients with a body weight greater than 75 kg or when a concomitant tricuspid valve (TV) procedure and/or atrial septal defect closure is performed. A single dosage of crystalloid-based cardioplegia [Custodial- histidine-trypthophan-ketoglutarate (Custodial-HTK)] administered via the aortic root in combination with moderate hypothermia (34-35 °C) has become the standard of care for induction and maintenance of myocardial protection at our institution. The present article highlights and discusses the principal techniques of myocardial protection for Mini-MV.
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Affiliation(s)
- Jens Garbade
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | - Piroze Davierwala
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | - Joerg Seeburger
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | | | - Martin Misfeld
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
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Ghoreishi M, Dawood M, Hobbs G, Pasrija C, Riley P, Petrose L, P. Griffith B, Gammie JS. Repeat Sternotomy: No Longer a Risk Factor in Mitral Valve Surgical Procedures. Ann Thorac Surg 2013; 96:1358-1365. [DOI: 10.1016/j.athoracsur.2013.05.064] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 05/13/2013] [Accepted: 05/17/2013] [Indexed: 11/16/2022]
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Abstract
The transition of mitral valve surgery away from the traditional sternotomy approach toward more minimally invasive strategies continues to evolve. The use of telemanipulative robotic arms with near 3-dimensional valve visualization has allowed for near complete endoscopic robotic-assisted mitral valve surgery, providing increased patient satisfaction and cosmesis. Studies have shown rapid recovery times without sacrificing perioperative safety or the durability of surgical repair. Although a steep learning curve exists as well as high fixed and disposable costs, continued technological development fueled by increasing patient demand may allow for further expansion in the use of robotic-assisted minimal invasive surgery.
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Affiliation(s)
- William Vernick
- Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University Hosptial of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Wilhelmi M, Rodt T, Ismail I, Haverich A. Aortic valve replacement via right anterolateral thoracotomy in the case of a patient with extreme mediastinal right-shift following pneumonectomy. J Cardiothorac Surg 2013; 8:20. [PMID: 23351283 PMCID: PMC3622622 DOI: 10.1186/1749-8090-8-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 01/23/2013] [Indexed: 11/10/2022] Open
Abstract
We report on the case of a 68-year-old male patient with the history of right pneumonectomy due to bronchial carcinoma, who was referred for aortic valve replacement due to severe calcified aortic stenosis. Pre-operative chest X-ray and computed tomography (CT) revealed an unusually pronounced mediastinal shift to the right. Despite this unusual anatomy, we decided to perform surgery using the right anterolateral thoracotomy following thorough pre-operative planning using 3D-volume rendering of the CT data-set. This approach yielded excellent exposure of the aortic root and the ascending aorta, respectively. Following an uneventful operative and post-operative course the patient could be discharged on post-OP day 6.Although only occasionally described for aortic valve replacement a right anterolateral thoracotomy may represent a valuable surgical approach, particular in patients with unusual anatomy, e.g. a mediastinal right-shift. However, thorough pre-operative planning, i.e. using visualization and planning techniques such as 3D-volume rendering should be mandatory as it provides information crucial to facilitate surgical steps and thus, may help avoid severe surgical complications.
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Affiliation(s)
- Mathias Wilhelmi
- Division for Cardiac, Thoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str, 1, Hannover, 30625, Germany.
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Al Kindi AH, Salhab KF, Kapadia S, Roselli EE, Krishnaswamy A, Grant A, Murat Tuzcu E, Svensson LG. Simultaneous transapical transcatheter aortic and mitral valve replacement in a high-risk patient with a previous mitral bioprosthesis. J Thorac Cardiovasc Surg 2012; 144:e90-1. [DOI: 10.1016/j.jtcvs.2012.05.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 05/07/2012] [Accepted: 05/16/2012] [Indexed: 10/28/2022]
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Double closure repair of mitral paravalvular leak by way of right thoracotomy. J Thorac Cardiovasc Surg 2012; 143:1452-3. [DOI: 10.1016/j.jtcvs.2011.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 10/26/2011] [Accepted: 11/08/2011] [Indexed: 11/20/2022]
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Klokocovnik T, Kersnik Levart T, Bunc M. Double venous drainage through the superior vena cava in minimally invasive aortic valve replacement: a retrospective study. Croat Med J 2012; 53:11-6. [PMID: 22351573 PMCID: PMC3284179 DOI: 10.3325/cmj.2012.53.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aim To compare the outcomes of patients who underwent upper mini-sternotomy or right mini-thoracotomy and those who underwent full sternotomy and to report a technical improvement in venous drainage by means of double venous cannulation of the superior vena cava (SVC) in mini surgical procedures. Methods We retrospectively analyzed the outcome of 217 patients who underwent aortic valve replacement through upper mini-sternotomy or right mini-thoracotomy at the Department of Cardiovascular Surgery, University Medical Centre Ljubljana, Slovenia from 1996 till 2010. Cannulation of SVC and right atrial appendage was performed in 142/217 (65%) patients, while in the remaining 75 (35%) patients, double cannulation of SVC was used for venous drainage. The results of patients who underwent mini approaches were compared to 236 patients who underwent full sternotomy for the same purpose from 2009 to 2010 at the same center. Results We found a shorter mean length of intensive care unit stay, less volume chest-tube drainage, shorter crossclamp and cardio pulmonary bypass times, and less postoperative permanent pacemaker implantations in the minimally invasive group patients than in full sternotomy group patients. Using double cannulation of the SVC for venous drainage made venous cannulation in mini approaches easier and eliminated the need for obtaining femoral venous access. Conclusion Our study confirmed that even though technically challenging, upper mini-sternotomy and right mini-thoracotomy approaches for aortic valve replacement have potential advantages over conventional median sternotomy. They were proved to be safe, efficacious, and can significantly reduce surgical trauma and are therefore particularly valuable in some higher risk, obese, diabetic and elderly patients. Using double cannulation of SVC for venous drainage made venous cannulation easier and eliminated the need for obtaining femoral venous access.
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Affiliation(s)
- Tomislav Klokocovnik
- Department of Cardiovascular Surgery, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, Slovenia.
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Arcidi JM, Rodriguez E, Elbeery JR, Nifong LW, Efird JT, Chitwood WR. Fifteen-year experience with minimally invasive approach for reoperations involving the mitral valve. J Thorac Cardiovasc Surg 2012; 143:1062-8. [DOI: 10.1016/j.jtcvs.2011.06.036] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 06/09/2011] [Accepted: 06/28/2011] [Indexed: 12/01/2022]
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Grossi EA, Loulmet DF, Schwartz CF, Ursomanno P, Zias EA, Dellis SL, Galloway AC. Evolution of operative techniques and perfusion strategies for minimally invasive mitral valve repair. J Thorac Cardiovasc Surg 2012; 143:S68-70. [PMID: 22285326 DOI: 10.1016/j.jtcvs.2012.01.011] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Revised: 11/13/2011] [Accepted: 01/04/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Perfusion strategies and operative techniques for minimally invasive mitral valve repair have evolved over time. During the past decade, our institution's approach has progressed from a port access platform with femoral perfusion to predominantly a central aortic cannulation through a right anterior minithoracotomy incision. We analyzed this institutional experience to evaluate the impact of approach on patient outcomes. METHODS Between 1995 and 2007, 1282 patients (mean age, 59.3 years; range, 18-99 years) underwent first-time, isolated mitral valve repair using a minimally invasive technique. Patient demographics included peripheral vascular disease (3.2%), chronic obstructive pulmonary disease (8.3%), atherosclerotic aorta (6.5%), cerebrovascular disease (4.3%), and ejection fraction less than 30% (4.3%). Retrograde perfusion was performed in 394 (30.7%) of all patients and endoaortic balloon occlusion in 373 (29.1%); the operative technique was a right anterior minithoracotomy in 1264 (98.6%) and left posterior minithoracotomy in 18 (1.4%). The etiology of mitral disease was degenerative in 73.2%, functional in 20.6%, and rheumatic in 2.4%. Data were collected prospectively using the New York State Cardiac Surgery Report System and a customized minimally invasive surgery data form. Logistic analysis was used to evaluate risk factors and outcomes; operative experience was divided into tertiles. RESULTS Overall hospital mortality was 2.0% (25/1282). Mortality was 1.1% (10/939) for patients with degenerative etiology and 0.4% (3/693) for patients younger than 70 years of age with degenerative valve disease. Risk factors for death were advanced age (P = .007), functional etiology (P = .010; odds ratio [OR] = 3.3), chronic obstructive pulmonary disease (P = .013; OR = 3.4), peripheral vascular disease (P = .014; OR = 4.2), and atherosclerotic aorta (P = .03; OR = 2.8). Logistic risk factors for neurologic events were advanced age (P = .02), retrograde perfusion (P = .001; OR = 3.8), and emergency procedure (P = .01; OR = 66.6). Interaction modeling revealed that the only significant risk factor for neurologic event was the use of retrograde perfusion in high-risk patients with aortic disease (P = .04; OR = 8.5). Analysis of successive tertiles during this 12-year experience revealed a significant decrease in the use of retrograde arterial perfusion (89.6%, 10.4%, and 0.0%; P < .001) and endoaortic balloon occlusion (89.3%, 10.7%, and 0%; P < .001). The overall frequency of postoperative neurologic events was 2.3% (30/1282) and decreased from 4.7% in the first tertile to 1.2% in the second and third tertiles (P < .001). CONCLUSIONS Central aortic cannulation through a right anterior minithoracotomy for mitral valve repair allows excellent outcomes in patients with a broad spectrum of comorbidities and has become our preferred approach for most patients undergoing mitral valve repair. Retrograde arterial perfusion is associated with an increased risk of stroke in patients with severe peripheral vascular disease and should be reserved for select patients without significant atherosclerosis.
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Affiliation(s)
- Eugene A Grossi
- Department of Cardiothoracic Surgery, New York University Medical Center, New York, NY 10016, USA.
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Beating heart surgery via right thoracotomy for reoperative mitral valve surgery: a safe and effective operative alternative. J Thorac Cardiovasc Surg 2011; 144:334-9. [PMID: 22050983 DOI: 10.1016/j.jtcvs.2011.09.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 08/04/2011] [Accepted: 09/21/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Right thoracotomy using ventricular fibrillation with cooling has been used for redo mitral valve surgery. This approach avoids the complications of redo sternotomy, such as injury to prior grafts and hemorrhage. As a further refinement, we have used a beating heart technique to further minimize complications while simplifying the operation. METHODS We reviewed the outcomes of 450 patients who underwent redo mitral valve surgery via a right thoracotomy from 1996 to 2011 at the University of Michigan. Of these, 134 patients underwent redo mitral valve surgery with ventricular fibrillation, and 316 patients underwent beating heart surgery. Although operative eras were consecutive, patients' age, risk factors, New York Heart Association, and preoperative left ventricular ejection fraction were not significantly different. Core temperature on cardiopulmonary bypass for beating heart surgery was 32°C versus 26°C for ventricular fibrillation. RESULTS Patients undergoing beating heart surgery had shorter periods of cardiopulmonary bypass: 81±9 minutes versus 113±36 minutes. Beating heart surgery required less blood products than ventricular fibrillation: 1.65±2 units versus 3.8±5 units packed red blood cells, 0.6±1.2 units versus 1.8±4 units fresh-frozen plasma, and 1.02±4 versus 7.5±17 platelet packs (all P<.01). Conversely, patients receiving ventricular fibrillation required longer postoperative ventilation: 34±101 hours versus 15.5±27 hours (P<.01). The 30-day mortality was similar for both (6.5% for beating heart and 7.4% for ventricular fibrillation), and postoperative length of stay was the same at 7 days. Stroke rate was 2.6% for patients undergoing beating heart surgery and 3% for patients receiving ventricular fibrillation. Significant operative complications were uncommon; there was no catastrophic hemorrhage, and only 2 patients receiving ventricular fibrillation and 2 patients undergoing beating heart surgery required reexploration. CONCLUSIONS As reoperative cardiac surgery continues to increase, techniques that safely facilitate operation while improving outcome should be adopted. As an operative alternative, redo right thoracotomy mitral valve surgery on the beating heart is associated with shorter bypass time, less transfusion requirements, shorter postoperative ventilation, and lower mortality. This safe and effective approach should be considered for this complex operation.
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Akiyama K, Nakata KI, Kashiwazaki S, Fukushima S. Aortic balloon used in a cardiac reoperation of a patient with patent coronary grafts. Ann Thorac Cardiovasc Surg 2011; 17:86-9. [PMID: 21587138 DOI: 10.5761/atcs.cr.09.01422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 10/28/2009] [Indexed: 11/16/2022] Open
Abstract
Reoperation in patients with patent coronary artery bypass grafts behind the sternum is associated with a high risk of graft injury that may be life-threatening. We recently performed mitral valve replacement in a patient with patent coronary artery bypass grafts and grade IV mitral regurgitation. Surgery was safely performed with minimal adhesion dissection and modified Port-Access Technique using an aortic balloon.
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Affiliation(s)
- Kenji Akiyama
- Department of Cardiovascular Surgery, Nihon University Nerima Hikarigaoka Hospital, 2-11-1 Hikarigaoka, Nerima-ku, Tokyo, Japan.
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Takahashi H, Okada K, Matsumori M, Okita Y. Aortic root replacement through right anterolateral thoracotomy. Interact Cardiovasc Thorac Surg 2010; 11:345-7. [PMID: 20525762 DOI: 10.1510/icvts.2010.237578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 59-year-old woman had undergone total arch replacement, followed by the mediastinal omental flap installation because of postoperative mediastinitis. One year later, she was diagnosed with annuloaortic ectasia with mitral regurgitation and underwent aortic root replacement (modified Bentall procedure) plus mitral valve annuloplasty through the right anterolateral thoracotomy. Her postoperative course was uneventful. The approach could be an alternative for the aortic root replacement in patients with previous median sternal wound complications.
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Affiliation(s)
- Hideki Takahashi
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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Morales D, Williams E, John R. Is resternotomy in cardiac surgery still a problem? Interact Cardiovasc Thorac Surg 2010; 11:277-86. [PMID: 20525761 DOI: 10.1510/icvts.2009.232090] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Multiple factors contribute to the growing number of reoperations for congenital and acquired cardiovascular diseases in the United States. Although the hazards are well-recognized, the health economic burden of resternotomy (RS) remains unclear and may be difficult to quantify. Contrary to published studies citing low frequencies of catastrophic hemorrhage and mortality, survey responses from practicing surgeons disclose higher rates of complications. Safety strategies in cardiac reoperation have generally involved efforts to maximize visualization during dissection, specialized surgical maneuvers and instrumentation, customized methods for establishing extracorporeal circulation, and techniques to prevent or avoid retrosternal adhesions. Yet, the relative cost-effectiveness of these strategies is largely unexplored. With the ongoing constraints in healthcare budgets, differentiating the value of existing and future approaches in terms of relative clinical benefits, costs, and impact on resource utilization will become increasingly important. We reviewed the relevant published literature in order to survey the morbidity and resource utilization associated with RS in cardiac reoperation and to identify key issues relevant for future studies.
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Affiliation(s)
- David Morales
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, MC-WT 19345H, Houston, TX 77030, USA.
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Crooke GA, Schwartz CF, Ribakove GH, Ursomanno P, Gogoladze G, Culliford AT, Galloway AC, Grossi EA. Retrograde Arterial Perfusion, Not Incision Location, Significantly Increases the Risk of Stroke in Reoperative Mitral Valve Procedures. Ann Thorac Surg 2010; 89:723-9; discussion 729-30. [DOI: 10.1016/j.athoracsur.2009.11.061] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 11/20/2009] [Accepted: 11/23/2009] [Indexed: 11/25/2022]
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Meyer SR, Szeto WY, Augoustides JG, Morris RJ, Vernick WJ, Paschal D, Fox J, Hargrove WC. Reoperative Mitral Valve Surgery by the Port Access Minithoracotomy Approach Is Safe and Effective. Ann Thorac Surg 2009; 87:1426-30. [DOI: 10.1016/j.athoracsur.2009.02.060] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 02/18/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
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Hybrid Cardiovascular Procedures. JACC Cardiovasc Interv 2008; 1:459-68. [PMID: 19463346 DOI: 10.1016/j.jcin.2008.07.002] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 07/08/2008] [Accepted: 07/12/2008] [Indexed: 11/22/2022]
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Left Thoracotomy for Multiple-Time Redo Mitral Valve Surgery Using On-Pump Beating Heart Technique. Ann Thorac Surg 2008; 86:466-71. [DOI: 10.1016/j.athoracsur.2008.04.050] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/10/2008] [Accepted: 04/14/2008] [Indexed: 11/23/2022]
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Safety of Minimally Invasive Mitral Valve Surgery Without Aortic Cross-Clamp. Ann Thorac Surg 2008; 85:1544-9; discussion 1549-50. [DOI: 10.1016/j.athoracsur.2008.01.099] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 01/27/2008] [Accepted: 01/28/2008] [Indexed: 11/17/2022]
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Svensson LG. Minimally Invasive Surgery with a Partial Sternotomy “J” Approach. Semin Thorac Cardiovasc Surg 2007; 19:299-303. [DOI: 10.1053/j.semtcvs.2007.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2007] [Indexed: 11/11/2022]
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