Minimally invasive aortic valve replacement using right minithoracotomy is associated with better outcomes than ministernotomy

Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis

In recent years, minimally invasive cardiac surgery has increased in prevalence. There has been significant debate regarding the optimal approach to isolated aortic valve replacement between conventional midline sternotomy and minimally invasive approaches. We performed a systematic review of the contemporary literature comparing minimally invasive to full sternotomy aortic valve replacement. PubMed and Embase were systematically searched for articles published from 2010-2021. A total of 1215 studies were screened and 45 studies (148,606 patients total) met the inclusion criteria. This study found rates of in-hospital mortality were higher with full sternotomy than ministernotomy ( P = 0.02). 30-day mortality was higher with full sternotomy compared to right anterior thoracotomy ( P = 0.006). Renal complications were more common with full sternotomy versus ministernotomy ( P < 0.00001) and right anterior thoracotomy ( P < 0.0001). Rates of wound infections were greater with full sternotomy than ministernotomy ( P = 0.02) and right anterior thoracotomy ( P < 0.00001). Intensive care unit length of stay ( P = 0.0001) and hospital length of stay ( P < 0.0001) were shorter with ministernotomy compared to full sternotomy. This review found that minimally invasive approaches to isolated aortic valve replacement result in reduced early mortality and select measures of postoperative morbidity; however, long-term mortality is not significantly different based on surgical approach. An analysis of mortality alone is not sufficient for the selection of the optimal approach to isolated aortic valve replacement. Surgeon experience, individual patient characteristics, and preference require thorough consideration, and additional studies investigating quality of life measures will be imperative in identifying the optimal approach to isolated aortic valve replacement.

Upper partial sternal split for pediatric cardiac surgery

OBJECTIVES

We introduced the use of an upper partial sternal split for pediatric cardiac surgical procedures in our unit in 2016. We report the outcomes of our experience in 51 patients using this approach.

METHODS

From February 2016 to September 2022, 51 patients underwent congenital cardiac surgical procedures using an upper partial sternal split including vascular ring repair (n = 20), subaortic membrane (n = 12), ventricular septal defect closure with aortic valve resuspension (n = 9), aortic arch repair (n = 4), pulmonary artery band (n = 2), pulmonary artery sling (n = 1), supravalvular aortic stenosis (n = 1), aortic valve replacement (n = 1), and pulmonary artery plasty (n = 1). The surgical approach involved a midline skin incision, based on the manubrium, followed by an upper manubriotomy. No special surgical instrumentation was required. Median patient age was 2.9 years (IQR 1.3, 6.0); median body weight was 15 kg (IQR 9.8, 20).

RESULTS

There was no mortality and no patient required intraoperative conversion to full sternotomy. One patient required re-exploration for bleeding when the incision was converted to a full sternotomy. There were no wound complications in any patient. Twenty-one patients (41%) were extubated on the table and of the remaining 30 patients, 23 patients (76%) were extubated within 24 h of surgery. Eleven patients did not require intensive care unit (ICU) admission. Median ICU and hospital stay was 1 day (IQR 1, 1.25) and 5 days (IQR 4, 8) ,respectively.

CONCLUSION

An upper partial sternal split approach is straightforward and can be performed safely with a preferable cosmetic result in selected pediatric cardiac operations.

Network Meta-Analysis Comparing Transcatheter, Minimally Invasive, and Conventional Surgical Aortic Valve Replacement

The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but time-varying outcomes have yet to be comprehensively explored. This study aimed to compare the all-cause mortality among 3 AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional AVR (CAVR). An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI with CAVR and RCTs or propensity score-matched (PSM) studies comparing MIAVR with CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality were derived from graphical reconstruction of Kaplan-Meier curves. Pairwise comparisons and network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk, as well as patients who underwent transfemoral (TF) TAVI. A total of 27 studies with 16,554 patients were included. In the pairwise comparisons, TAVI showed superior mortality to CAVR until 37.5 months, beyond which there was no significant difference. When restricted to TF TAVI versus CAVR, a consistent mortality benefit favoring TF TAVI was seen (shared frailty hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.76 to 0.98, p = 0.024). In the network meta-analysis involving majority PSM data, MIAVR demonstrated significantly lower mortality than TAVI (HR = 0.70, 95% CI = 0.59 to 0.82) and CAVR (HR = 0.69, 95% CI = 0.59 to 0.80); this association remained compared with TF TAVI but with a lower extent of benefit (HR = 0.80, 95% CI = 0.65 to 0.99). In conclusion, the initial short- to medium-term mortality benefit for TAVI over CAVR was attenuated over the longer term. In the subset of patients who underwent TF TAVI, a consistent benefit was found. Among majority PSM data, MIAVR showed improved mortality compared with TAVI and CAVR but less than the TF TAVI subset, which requires validation by robust RCTs.

Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery

OBJECTIVES

Ministernotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.

METHODS

The data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).

RESULTS

After propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan-Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).

CONCLUSIONS

Minimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.

Comparison of Right Anterior Mini-Thoracotomy Versus Partial Upper Sternotomy in Aortic Valve Replacement

Introduction

Propensity score analysis of midterm outcomes after isolated aortic valve replacement through right anterior mini-thoracotomy and partial upper sternotomy could provide information about the most beneficial minimally invasive technique for the patient based on the preoperative risk factors.

Methods

Between March 2015 and February 2021, 694 minimally invasive isolated aortic valve surgeries were performed at our institution. Among these, 441 right anterior mini-thoracotomies and 253 partial upper sternotomies were performed. A propensity score analysis was performed in 202 matched pairs.

Results

Cardiopulmonary bypass time and cross-clamp time were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.001 and p < 0.001, respectively). Time to first mobilization and hospital stay were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.005, p = 0.001, respectively). A significantly lower incidence of revision surgery was noted in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.046). No significant differences in 30-day mortality (p = 1.000) and 1-year mortality (p = 0.543) were noted. Kaplan-Meier survival estimates were 96.3% in the right anterior mini-thoracotomy group and 92.7% in the partial upper sternotomy group after 4 years (log rank 0.169), respectively.

Conclusions

Despite the technical challenges, right anterior mini-thoracotomy can be chosen as first-line strategy for isolated aortic valve replacement. For patients unsuitable for this technique, the partial upper sternotomy remains a safe method that can be performed by a wide range of surgeons.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02263-6.

A Decision-Support Informatics Platform for Minimally Invasive Aortic Valve Replacement

Minimally invasive aortic valve replacement is performed by mini-sternotomy (MS) or less invasive right anterior mini-thoracotomy (RT). The possibility of adopting RT is assessed by anatomical criteria derived from manual 2D image analysis. We developed a semi-automatic tool (RT-PLAN) to assess the criteria of RT, extract other parameters of surgical interest and generate a view of the anatomical region in a 3D space. Twenty-five 3D CT images from a dataset were retrospectively evaluated. The methodology starts with segmentation to reconstruct 3D surface models of the aorta and anterior rib cage. Secondly, the RT criteria and geometric information from these models are automatically and quantitatively evaluated. A comparison is made between the values of the parameters measured by the standard manual 2D procedure and our tool. The RT-PLAN procedure was feasible in all cases. Strong agreement was found between RT-PLAN and the standard manual 2D procedure. There was no difference between the RT-PLAN and the standard procedure when selecting patients for the RT technique. The tool developed is able to effectively perform the assessment of the RT criteria, with the addition of a realistic visualisation of the surgical field through virtual reality technology.

Mini-Invasive Bentall Procedure Performed via a Right Anterior Thoracotomy Approach With a Costochondral Cartilage Sparing

Objectives

A right minithoracotomy approach with a sternal sparing technique is a minimally invasive option for surgeons performing aortic root surgery. This report presents our initial clinical results of the right minithoracotomy Bentall procedure.

Methods

Clinical data of 15 patients were retrospectively analyzed who underwent the minimally invasive Bentall procedure through the right anterior thoracotomy via the second intercostal incision without any costochondral cartilage invasion at our institution between October, 2019 and June, 2021. The operative time, length of intensive care unit stay and postoperative hospital stay, perioperative outcomes, and follow-up results were analyzed.

Results

The median aortic cross-clamping time was 95.0 (85.5–98.8) min. Three (21.4%) patients received blood transfusion. The median drainage volume in the first 24 h was 200.0 ml, with no redo for bleeding. The median duration of mechanical ventilation was 12.5 (11.0–25.0) h, and median length of intensive care unit stay was 1.5 (1.0–3.0) day. All patients discharged 5.8 ± 1.2 days following surgery, with no dead patients found. At 6 months following surgery, all patients survived with an improved New York Heart Association (NYHA) functional class.

Conclusion

The right minithoracotomy Bentall procedure may be performed safely with low morbidity and mortality. This approach should be considered as an option in carefully selected patients requiring aortic root replacement.

Aortic valve replacement via right anterolateral minithoracotomy: preventing adverse events during the initial learning curve

BACKGROUND

Despite excellent outcomes and reduced invasiveness, the right anterolateral thoracotomy approach for aortic valve replacement (RALT-AVR) has not been broadly adopted. This study provides results regarding the initial experience and learning curve of a single surgeon performing this procedure.

METHODS

Periprocedural details and postoperative outcomes of the first 100 consecutive patients who underwent RALT-AVR at our institution were retrospectively analyzed. We conducted a cumulative sum analysis of surgical failure, defined as occurrence of 30-day-mortality, surgical revision for bleeding, conversion to sternotomy, 3^rd degree heart block, paravalvular leakage, postoperative stroke or mean transvalvular gradient >20 mmHg.

RESULTS

The cohort was of low surgical risk (mean EuroSCORE II 1.31%±0.85, mean STS PROM 1.45%±0.97), 58% were males. Median cross-clamp time was 67.5 (57.8-76) min, median CPB time 105 (91.8-119) min, and median operation time 164.5 (144.5-183.2) min. There were no conversions to full sternotomy, 4 cases of revision for bleeding and 2 pacemaker implantations for 3^rd degree heart block. Prosthesis function was good (median ΔPmean 10.9 [7.4-13.6] mmHg). Thirty-day-mortality was 0%. The log-likelihood graph never crossed the upper boundary, and after a steady decrease, crossed the lower boundary at 93 patients.

CONCLUSIONS

RALT-AVR can be performed with acceptable procedural times and satisfactory outcomes. For a well-trained surgeon, adapting to this new procedure does not expose patients to an increased risk, when patient selection and procedural planning are applied appropriately. Cumulative sum failure analysis is an appropriate tool to monitor the transition from standard AVR to the technically more demanding RALT-AVR.

Rhythm outcomes after aortic valve surgery: Treatment and evolution of new-onset atrial fibrillation

BACKGROUND

The impact of new-onset atrial fibrillation (AF) after aortic valve (AV) surgery on mid- and long-term outcomes is under debate. Here, we sought to follow up heart rhythms after AV surgery, and to evaluate the mid-term prognosis and effectiveness of treatment for patients with new-onset AF.

METHODS

This single-center cohort study included 978 consecutive patients (median age, 59 years; male, 68.5%) who underwent surgical AV procedures between 2017 and 2018. All patients with postoperative new-onset AF were treated with Class III antiarrhythmic drugs with or without electrical cardioversion (rhythm control). Status of survival, stroke, and rhythm outcomes were collected and compared between patients with and without new-onset AF.

RESULTS

New-onset AF was detected in 256 (26.2%) patients. For them, postoperative survival was comparable with those without new-onset AF (1-year: 96.1% vs. 99.3%; adjusted P = .30), but rate of stroke was significantly higher (1-year: 4.0% vs. 2.2%; adjusted P = .020). With rhythm control management, the 3-month and 1-year rates of paroxysmal or persistent AF between patients with and without new-onset AF were 5.1% versus 1.3% and 7.5% versus 2.1%, respectively (both P < .001). Multivariate models showed that advanced age, impaired ejection fraction, new-onset AF and discontinuation of beta-blockers were predictors of AF at 1 year.

CONCLUSIONS

In most cases, new-onset AF after AV surgery could be effectively converted and suppressed by rhythm control therapy. Nevertheless, new-onset AF predisposed patients to higher risks of stroke and AF within 1 year, for whom prophylactic procedures and continuous beta-blockers could be beneficial.

Anatomical circumstances and aortic cross-clamp time in minimally invasive aortic valve replacement

OBJECTIVES

Prolonged operative times, potentially leading to increased morbidity, are a possible drawback of minimally invasive aortic valve replacement. The aim of this study was to assess the impact of anatomical circumstances in the chest on aortic cross-clamp time.

METHODS

This retrospective study included 68 patients who underwent minimally invasive aortic valve replacement with the Perceval sutureless valve via right-anterior thoracotomy or with ministernotomy. Anatomical variables were measured during preoperative computer tomography scans.

RESULTS

Aortic cross-clamp time was shorter in those having ministernotomy than in the right-anterior thoracotomy group (41.1 vs 52.3 min; P < 0.001). Cardiopulmonary bypass (CPB) time was not significantly different between groups (P = 0.09). A multivariable linear-regression model (P = 0.018) showed the aortic dextroposition variable to be a significant predictor of the aortic cross-clamp method and CPB times (P = 0.005 and P = 0.003) independent of other anatomical variables in the right thoracotomy group (10 mm deviation from optimal position prolonged the times for 240 and 600 s). For the whole cohort, a correlation between aortic valve dimensions and operative times was found (P = 0.046, P = 0.009). A linear-regression model (P = 0.046) predicted 90 s longer aortic cross-clamp time and 231 s longer CPB time for every 1 mm smaller aortic valve diameter.

CONCLUSIONS

The anatomical variables are associated with the operative times in minimally invasive aortic valve replacement with sutureless valves. Considering this association, preplanning the procedure is recommended.

Minimally invasive access type related to outcomes of sutureless and rapid deployment valves

OBJECTIVES

Minimally invasive surgical techniques with optimal outcomes are of paramount importance. Sutureless and rapid deployment aortic valves are increasingly implanted via minimally invasive approaches. We aimed to analyse the procedural outcomes of a full sternotomy (FS) compared with those of minimally invasive cardiac surgery (MICS) and further assess MICS, namely ministernotomy (MS) and anterior right thoracotomy (ART).

METHODS

We selected all isolated aortic valve replacements in the Sutureless and Rapid Deployment Aortic Valve Replacement International Registry (SURD-IR, n = 2257) and performed propensity score matching to compare aortic valve replacement through FS or MICS (n = 508/group) as well as through MS and ART accesses (n = 569/group).

RESULTS

Postoperative mortality was 1.6% in FS and MICS patients who had a mean logistic EuroSCORE of 11%. Cross-clamp and cardiopulmonary bypass (CPB) times were shorter in the FS group than in the MICS group (mean difference 3.2 and 9.2 min; P < 0.001). Patients undergoing FS had a higher rate of acute kidney injury (5.6% vs 2.8%; P = 0.012). Direct comparison of MS and ART revealed longer mean cross-clamp and CPB times (12 and 16.7 min) in the ART group (P < 0.001). The postoperative outcome revealed a higher stroke rate (3.2% vs 1.2%; P = 0.043) as well as a longer postoperative intensive care unit [2 (1-3) vs 1 (1-3) days; P = 0.009] and hospital stay [11 (8-16) vs 8 (7-12) days; P < 0.001] in the MS group than in the ART group.

CONCLUSIONS

According to this non-randomized international registry, FS resulted in a higher rate of acute kidney injury. The ART access showed a lower stroke rate than MS and a shorter hospital stay than all other accesses. All these findings may be related to underlying patient risk factors.

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

Background

Early treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve.

Methods

SURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected.

Results

The study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study.

Conclusions

These results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.

Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center

OBJECTIVE

The goal of this manuscript was to report the clinical outcomes of the initial series of 100 consecutive Right Anterior Mini Thoracotomy (RAMT) aortic valve replacement (AVR) implantations at a Canadian Center.

METHODS

This retrospective study reported the clinical outcomes of the first 100 patients who underwent the RAMT approach for isolated surgical AVR in Calgary, Canada, between 2016 and 2020. Primary outcomes were death within 30 days of surgery and disabling stroke. Secondary outcomes included surgical times, the need for permanent pacemaker (PPM), incidence of postoperative blood transfusion in the intensive care unit (ICU), postsurgical atrial fibrillation (AF), length of ICU/hospital stay, postsurgical AF, residual paravalvular leak (PVL), postoperative transvalvular gradient, need for postsurgical intravenous opioids, duration of invasive ventilation in the ICU, and chest tube output in the first 12 h postsurgery.

RESULTS

In this study, 54 patients were male, and the average age of the cohort was 72 years. Mortality within 30 days of surgery was 1% with no disabling postoperative strokes. Mean cardiopulmonary bypass and cross clamp was 84 and 55 min, respectively. PPM rate was 3%, incidence of blood transfusion in the ICU was 4%, and the rate of postoperative AF was 23%. Median length of ICU and hospital stay was 1 and 5 days, respectively. Rate of mild or greater residual PVL was 3%, while the average residual transvalvular mean gradient was 8.5 mmHg.

CONCLUSION

The sternum-sparing RAMT approach can be safely integrated into surgical practice as a minimally invasive alternative for isolated AVR, and can reduce postoperative bleeding and narcotic requirements.

The First 100 Cases of Two Innovations Combined: Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Mini-Thoracotomy Using a Novel Aortic Prosthesis

Introduction

Aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is less traumatic than via other surgical routes; using a novel aortic valve may confer long-term resistance against valve deterioration, and thus be useful in younger, more active patients. Here we aim to validate using the INSPIRIS RESILIA valve with minimally invasive RAMT.

Methods

Between April 2017 and June 2019, 100 patients underwent video-assisted minimally invasive AVR by RAMT, using the INSPIRIS RESILIA aortic valve. Cannulation for cardiopulmonary bypass (CPB) was through femoral vessels. Clinical data were prospectively entered into our institutional database.

Results

Cardiopulmonary bypass (CPB) and cross-clamping times were 79 ± 38 and 41 ± 17 min. Surgical access was successful in 100% of cases. There were no cases of intraoperative mortality, 30-day mortality, cerebrovascular events, rethoracotomy for bleeding, valve-related reoperation, right internal mammary artery injury, or conversion to sternotomy. Intensive care and hospital stays were 2 ± 1 and 6 ± 3 days, respectively. One patient had a pacemaker fitted. Postoperative dialysis was necessary in one patient. Trace to mild aortic valve regurgitation occurred in two patients. No structural valve deterioration (SVD) and paravalvular leak were seen. At 1-year follow-up mean effective orifice area (EOA) was 1.8 ± 0.1 cm², peak gradient was 22.1 ± 3.1 mmHg, and mean gradient was 11.5 ± 2.3 mmHg.

Conclusion

Our preliminary experience suggests that RAMT for AVR using the INSPIRIS RESILIA aortic valve is safe, effective, and reproducible. Larger studies are needed to evaluate the long-term efficacy and durability of this new valve.

Minimally invasive aortic valve surgery

Since their introduction, it has been demonstrated that minimally invasive aortic valve replacement (MIAVR) approaches are safe and effective for the treatment of aortic valve diseases. To date, the main advantage of these approaches is represented by the reduced surgical trauma, with a subsequent reduced complication rate and faster recovery. This makes such approaches an appealing choice also for frail patients [obese, aged, chronic obstructive pulmonary disease (COPD)]. The standardization of the minimally invasive techniques, together with the implementation of preoperative workup and anesthesiological intra- and post-operative care, led to an amelioration of surgical results and reduction of surgical times. Moreover, the improvement of surgical technology and the introduction of new devices such as sutureless and rapid deployment (SURD) valves, has helped the achievement of comparable results to traditional surgery. However, transcatheter technologies are nowadays more and more important in the treatment of aortic valve disease, also in low risk patients. For this reason surgeons should put new efforts for further reducing the surgical trauma in the future, even taking inspiration from other disciplines. In this review, we aim to present a review of literature evidences regarding minimally invasive treatment of aortic diseases, also reflecting our personal experience with MIAVR techniques. This review could represent a tool for a well-structured patient assessment and preoperative planning, in order to safely carrying out an MIAVR procedure with satisfactory outcomes.

Clinical study of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision: The first Chinese experience

BACKGROUND

There is an increasing demand for minimally invasive aortic valve replacement. This study aimed to investigate the safety and feasibility of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision.

METHODS

This was a retrospective study, and we collected information from 111 patients who underwent isolated aortic valve replacement surgery performed by the same surgeon from January 2018 to December 2019. According to the operative approach, the patients were divided into a sternotomy aortic valve replacement (SAVR) group (n = 62) and a minimally invasive aortic valve replacement (Mini-AVR) group (n = 49). We compared the intraoperative and postoperative data between the two groups.

RESULT

There was no difference in preoperative data between the Mini-AVR and SAVR. The postoperative ventilator-assisted time, CSICU time and postoperative hospital stay of the Mini-AVR were shorter than those of the SAVR [(15.45 ± 5.75) VS (18.51 ± 6.71) h; (1.77 ± 0.31) VS (2.04 ± 0.63) d; (8.69 ± 2.75) VS (10.77 ± 2.94) d], and the difference was statistically significant (P < 0.05). Mini-AVR had lower postoperative drainage and blood transfusion rates in the first 24 h than SAVR [(109.86 ± 125.98) VS (508.84 ± 311.70) ml; 22.4% VS 46.8%], and the differences were statistically significant (P < 0.05). The incidence of postoperative AF in the Mini-AVR group was also lower than that in the SAVR group (10.2% VS 30.6%), and the differences were statistically significant (P < 0.05).

CONCLUSION

Mini-AVR has the advantages of less ventilator time, a reduced need for blood transfusion, less AF and a faster recovery. Mini-AVR is a safe and feasible surgical technique that is worthy of clinical application.

Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Minithoracotomy for All Comers With Aortic Valve Disease

OBJECTIVE

Right anterior minithoracotomy is a promising technique for aortic valve replacement and has shown excellent results in terms of mortality and morbidity. Against this background, we analyzed our institutional experience in this technique during the last 3 years.

METHODS

Between April 2017 and March 2019, 513 consecutive all comers with aortic valve disease underwent video-assisted minimally invasive aortic valve replacement through a 3-cm skin incision as right anterior minithoracotomy at our institution. A camera and automatic fastener technology were used for the valve implantation in all patients. Clinical data were prospectively entered into our institutional database.

RESULTS

Cardiopulmonary bypass time accounted for 68 ± 24 min and the myocardial ischemic time 38 ± 12 minutes. Thirty-day mortality and overall mortality was 0.4% (2 patients) and 1.4% (7 patients), respectively. Postoperative cerebrovascular events were noted in 8 patients (1.5%). Intensive care stay and hospital stay were 2 ± 2 and 9 ± 7 days, respectively. Pacemaker implantation, injury of the right internal mammary artery, and conversion to full sternotomy were noted in 7 patients (1.4%), 3 patients (0.6%), and 1 patient (0.2%), respectively. Paravalvular leak need to intervention was noted in 2 patients (0.4%). Rethoracotomy rate was 2% (11 patients). Transient postoperative dialysis was necessary for 14 patients (3%).

CONCLUSIONS

Video-assisted minimally invasive aortic valve replacement through the right anterior minithoracotomy is a safe approach and yields excellent outcomes in high-volume centers. The use of a camera and automatic fastener technology facilitates this procedure.

Minimally invasive aortic valve replacement with sutureless bioprosthesis through right minithoracotomy with completely central cannulation-Early results in 203 patients

OBJECTIVES

Minimally invasive aortic valve replacement (mini-AVR) might improve clinical outcomes, particularly in high-risk and elderly patients. Sutureless/rapid deployment bioprosthesis can offer advantage of decreasing the cross-clamp time (XCT) and easing the procedure. Our aim was to evaluate the safety and perioperative outcomes of mini-AVR using sutureless bioprothesis via the right minithoracotomy approach with our modified technique of central cannulation.

METHODS

We performed a single-center retrospective analysis of 203 patients consecutively undergoing isolated AVR between March 2016 and June 2018 with the right minithoracotomy approach and our modified technique of central cannulation. Aortic valve diseases were stenosis (89.9%), regurgitation (1.6%), and mixed valve disease (8.5%). Patients with concomitant procedures were excluded. Primary endpoints were 30-day and 4-month mortality.

RESULTS

Mean age was 76 ± 6.2 years, 63 (31%) patients were 80 years or older. Cardiopulmonary bypass and XCT were 60.5 (39-153) and 35 (24-76) min, respectively. Thirty-day and 4-month mortality were 1% (two patients). We have observed minor paravalvular leak (PVL) which occurred in seven patients (3.4%), and no moderate/severe PVL was found perioperatively. One patient developed moderate/severe PVL during the 4-month follow-up. There was no structural valve degeneration. Two (1%) patients needed conversion to full sternotomy, and two (1%) patients to ministernotomy.

CONCLUSIONS

Mini-AVR via the right minithoracotomy approach with central cannulation is an effective and safe procedure and demonstrates excellent early clinical outcomes. This approach can be particularly valuable in higher risk and elderly patients.

Right Anterior Mini-Thoracotomy for Discrete Fibromembranous Subaortic Stenosis

Discrete fibromembranous subaortic stenosis is a common type of subaortic stenosis causing clinically significant left ventricular outflow obstruction. Surgery for discrete subaortic stenosis is most often performed through a typical midline sternotomy. Herein, we present our experience with an adult patient who underwent a right mini-thoracotomy for subaortic membrane resection with central cannulation under direct operative vision.

Oversizing Increases Pacemaker Implantation Rate After Sutureless Minimally Invasive Aortic Valve Replacement

OBJECTIVE

Cardiac conduction system disturbances potentially leading to permanent pacemaker implantation are significant postoperative complications after aortic valve replacement. The aim of this study was to assess the impact of sutureless prosthetic valve oversizing on permanent pacemaker implantation rate.

METHODS

This multicenter retrospective study included 306 patients who underwent minimally invasive aortic valve replacement with the Perceval sutureless valve. Oversizing was determined by the implanted valve size indexed to body surface area. Data were analyzed with a multivariable logistic regression model.

RESULTS

This study confirmed excellent postoperative results for minimally invasive aortic valve replacement with right anterior minithoracotomy approach and rapid deployment sutureless valves. Mortality rate was 1%. Eighteen (5.9%) patients received a new permanent pacemaker. Multivariable logistic regression model (P = 0.05) found oversizing as significant risk factor (P = 0.017) for permanent postoperative pacemaker implantation independent of patient age. There was a significant negative correlation between the indexed implanted valve size and the mean and peak postoperative transvalvular gradients (P < 0.001).

CONCLUSIONS

Oversizing of sutureless prosthetic aortic valves is a risk factor for postoperative permanent pacemaker implantation. Proper sizing of Perceval is important to avoid complications and ensure optimal valve performance.

Right anterior minithoracotomy approach for resection of papillary fibroelastoma

BACKGROUND

Right anterior minithoracotomy (RAMT) is an alternative to full or partial sternotomy for accessing the aortic valve. The adoption of this approach for aortic valve replacement has been limited by its perceived technical complexity. Resection of a mobile aortic valve tumor is a simple procedure that is conventionally done through a sternotomy.

AIM

The following case describes the resection of an aortic valve papillary fibroelastoma through an RAMT.

MATERIALS & METHODS

This is a report on a single patient's case.

RESULTS

The fibroelastoma was safely excised through a RAMT approach.

DISCUSSION

An aortic valve fibroelastoma offers an ideal starting point for surgeons to begin using a RAMT approach.

CONCLUSION

The excision of aortic valve masses is a procedure that is well suited to minimally invasive strategies, and we suggest sternum-sparing RAMT is the optimal approach.

A Novel Computed Tomography Scan Tool for Patient Selection in Minithoracotomy Aortic Replacement

Right anterior minithoracotomy is gaining larger acceptance for isolated aortic valve replacement. In some patients, however, surgical exposure during the intervention may be challenging even for experienced surgeons or centers. In our opinion, proper preoperative selection of the patients by computed tomography scan seems mandatory. We routinely perform right anterior minithoracotomy, and over time, we have found that the angle between the right border of the sternum and the left side of the aorta, at the level of the pulmonary artery, helps with patient selection.

Rapid deployment aortic valve replacement through anterior right thoracotomy: Clinical outcomes and haemodynamic performance

BACKGROUND

The ease of implantation of the rapid deployment (RD) and sutureless valves has contributed to the adoption of anterior right thoracotomy (ART) approach for aortic valve replacement (AVR).

AIM OF THE STUDY

This study evaluates the safety and haemodynamic performance of minimally invasive AVR through ART using the RD valves.

METHODS

This is a retrospective, single-center review of a total of 50 consecutive patients who received RD-AVR through ART.

RESULTS

The median age of patients was 75 years (interquartile range [IQR]: 69-80), and median Euroscore II was 5.1 (IQR: 2.4-7.5). ART RD-AVR was successfully performed in all cases with no conversion to sternotomy, paravalvular leaks or need for valve explantation. The mean size of the implanted valve was 23.2  ± 2.3 mm. In-hospital mortality was 2%. The mean and maximum pressure gradients across the aortic prosthesis were 10 mm Hg (IQR: 9-12) and 19 mm Hg (IQR: 16-23).

CONCLUSIONS

Rapid deployment aortic valve replacement can be safely performed through anterior right thoracotomy wit excellent haemodynamic performance and low postoperative complications rate.

Aortic Valve Replacement by a Transaxillary Anterior Minithoracotomy Approach

A modified transaxillary approach for aortic valve disease to obtain the same exposure as the anterior minithoracotomy approach and to preserve the pectoralis major muscle is presented. When the patient's right shoulder is adducted horizontally, or the right arm is flexed anteriorly 90 degrees and adducted to the left, the right axilla comes close to the chest midline. That means that a right anterior thoracotomy can be made through the right axilla when the arm position is adjusted appropriately. The modified new approach is safe and faster than the conventional transaxillary approach, and it provides cosmetic advantages to the patient.

Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation?

Atrial fibrillation (AF) is the most common post-operative complication and tends to be the most common arrhythmia after cardiac surgery. The etiology and risk factors for post-operative AF are poorly understood, but older age, large left atrium, diffuse coronary artery disease, a history of AF paroxysms and in general, pre-existing cardiac conditions that cause restricting and susceptibility towards inflammation have been consistently linked with post-operative atrial fibrillation (POAF). It has been traditionally thought that post-operative AF is transient, well-tolerated, benign to the patient and self-limiting complication of cardiac surgery that was temporary and easily treated. However, recent evidence suggests that POAF may be more "malignant" than previously thought, associated with follow-up mortality and morbidity. Several minimally invasive approaches, including the right parasternal approach, upper and lower mini-sternotomy (MS), V-shaped, Z-shaped, inverse-T, J-, reverse-C and reverse-L partial MS, transverse sternotomy and right mini-thoracotomy, have been developed for cardiac surgery operations since 1993 and have been associated with better outcomes and lower perioperative morbidity compared to full sternotomy (FS). The common goal of several minimally invasive approaches is to reduce invasiveness and surgical trauma. According to a statement from the American Heart Association (AHA), the term "minimally invasive" refers to a small chest wall incision that does not include a FS. This review is aimed to evaluate the use of minimally invasive techniques like mini-sternotomy, mini-thoracotomy and hybrid techniques versus conventional techniques which are used in cardiac surgery and to compare the frequency of post-operative AF and its effect on post-operative complications, morbidity and mortality, after cardiac surgery operations with FS versus cardiac surgery operations with the use of minimally invasive techniques.

Bioprosthetic Aortic Valve Replacement in <50 Years Old Patients - Where is the Evidence?

Aortic valve disease is one of the most common valvular heart diseases in the cardiovascular category. Surgical replacement of the diseased aortic valve remains the definitive intervention for most diseases.

There is a clear consensus that in young patients who require aortic valve replacement, a mechanical prosthesis is the preferred choice due to its durable prosthesis without fear of wear and tear over time. However, this comes at the expense of increased risk of bleeding and thromboembolic events; in addition, there is a lack of strict evidence in using bioprosthesis in patients younger than 50 years. The objective of this review article is to assess the current evidence behind using bioprosthetic aortic valve in this young cohort.

Minimal invasive aortic valve replacement: associations of radiological assessments with procedure complexity

Objectives

Limited aortic annulus exposure during minimal invasive aortic valve replacement (mini-AVR) proves to be challenging and contributes to procedure complexity, resulting in longer procedure times. New innovations like sutureless valves have been introduced to reduce procedure complexity. Additionally, preoperative imaging could also contribute to reducing procedure times. Therefore, we hypothesize that Computed Tomography (CT)-image based measurements are associated with mini-AVR complexity.

Methods

One hundred patients who underwent a mini-sternotomy and had a preoperative CT scan were included. With a CT-based mini-AVR planning tool, we measured access distance, access angle, annulus dimensions, and calcium volume. The associations of these measurements with cardiopulmonary bypass (CPB) time and aortic cross-clamp (AoX) time were assessed using univariable and multivariable regression models. In the multivariable models, these measurements were adjusted for age and suture technique.

Results

In the univariable regression models, calcium volume and annulus dimensions were associated with longer CPB and AoX time. After adjusting for age and suture technique, increasing calcium volume was still associated with longer CPB (adjusted β-coefficient 0.002, 95%-CI (0.005, 0.019), p-value = 0.002) and AoX time (adjusted β-coefficient 0.010, 95%-CI (0.004, 0.016), p-value = 0.002). However, after adjusting for these confounders, the association between annulus dimensions and procedure times lost statistical significance.

Conclusion

Increase in calcium volume are associated with longer CPB and AoX times, with age and sutureless valve implantation as independent confounders. In contrast to previous studies, access angle was not associated with procedure complexity.

Recent advances in aortic valve replacement

Aortic valve replacement has stood the test of time but is no longer an operation that is exclusively approached through a median sternotomy using only sutured prostheses. Currently, surgical aortic valve replacement can be performed through a number of minimally invasive approaches employing conventional mechanical or bioprostheses as well as sutureless valves. In either case, the direct surgical access allows inspection of the valve, complete excision of the diseased leaflets, and debridement of the annulus in a controlled and thorough manner under visual control. It can be employed to treat aortic valve pathologies of all natures and aetiologies. When compared with transcatheter valves in patients with a high or intermediate preoperative predictive risk, conventional surgery has not been shown to be inferior to transcatheter valve implants. As our understanding of sutureless valves and their applicability to minimally invasive surgery advances, the invasiveness and trauma of surgery can be reduced and outcomes can improve. This warrants further comparative trials comparing sutureless and transcatheter valves.

Right Anterior Minithoracotomy for Aortic Valve Replacement: A Widely Applicable, Simple, and Stepwise Approach

Objective

A stepwise approach for right anterior minithoracotomy aortic valve replacement (RAT-AVR), without sutureless valves, special instruments, or preoperative imaging, was developed. We report our experience with this widely applicable, simplified approach.

Methods

Patients with a history of previous chest surgery, documented PVD, severe COPD, LVOT size <2.0 cm, and root size <2.8 cm were excluded. Chest CT was not mandatory. The stepwise surgical approach consists of 1) tolerability of single-lung ventilation; 2) 5-cm long incision on third right anterior ICS; 3) small pericardial opening to localize the aortic valve annular plane by digital palpation; 4) shingling of the correct rib to create a box field; 5) optimizing exposure with stay sutures; 6) femoral or central cannulation with right superior pulmonary vein venting and usual antegrade cardioplegia; 7) performing a standard AVR without adjunct instruments; and 8) reconstructing 1 costochondral cartilage.

Results

Fifty-five patients were operated. The mean age was 68.5 years (SD 10.4); 29.1% were female. Median STS PROM was 1.18 (0.4 to 6.6). Pump and cross-clamp times were 104.8 minutes (SD 27.9) and 73.2 minutes (SD 22.8), respectively. There was no need for a knot pusher. There was 1 conversion, 1 reopening for bleeding, and 1 pacemaker insertion. No patient had a stroke, MI, or death at 30 days. The median LOS was 6 days (3 to 19).

Conclusion

RAT-AVR can be applicable and performed safely in a wide range of patients by adopting a simple, stepwise approach with intraoperative assessment, without the need for special imaging, instrumentation, or advanced training.

Improved operative and recovery times with mini-thoracotomy aortic valve replacement

Background

The small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy.

Methods

We retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared.

Results

Of the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67–113) minutes; vs. 117 (93.5–139.5); vs. 102.5 (85.5–132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5–9) days; vs. 7 (5–14.5); vs 9 (6–15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)].

Conclusions

Minimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy.

Minimally invasive surgical aortic valve replacement

Minimally invasive aortic valve replacement (MIAVR) is defined as a surgical aortic valve replacement which involves smaller chest incisions as opposed to full sternotomy. It is performed using cardiopulmonary bypass with cardiac arrest. It benefits from potential advantages of a less invasive procedure. To date, over 14 000 MIAVR have been reported in the literature. Due to heterogeneity of the studies, different surgical techniques and mainly the non-randomised nature of these studies comparing MIAVR with conventional aortic valve replacement, it is difficult to draw definitive conclusions. The two main techniques of MIAVR are mini-sternotomy and right anterior mini-thoracotomy. Both techniques with other less common forms of MIAVR will be discussed in this review. The advantages, disadvantages and surgical pitfalls will be discussed. Some of the advantages include shorter intensive care and hospital stay, reduced perioperative blood loss, less pain, improved respiratory function and cosmesis. The possible disadvantage of longer bypass and cross-clamp times may be counter balanced by the recent sutureless and rapid deployment valves. Despite some of the benefits, MIAVR has not been adopted by a significant proportion of the surgeons possibly related to the learning curve and requirements for re-training. As MIAVR becomes more common, randomised trials comparing this technique with transcatheter aortic valve implantation is warranted. In addition, assessing quality of life including return to work and functional capacity is needed.

Right Mini-Thoracotomy Subaortic Membrane Resection

OBJECTIVE

Subaortic membrane is an anatomical intracardiac anomaly that may cause discrete subaortic stenosis and aortic insufficiency. Patients requiring subaortic membrane resection may benefit from a minimally invasive approach; however, subaortic membranes are typically resected through a median sternotomy. We present our initial clinical experience of adult patients who have undergone a mini-thoracotomy subaortic membrane resection.

METHODS

Eight patients who underwent an elective subaortic membrane resection performed through a mini-thoracotomy were retrospectively reviewed. A 5-cm mini-thoracotomy incision was made in the 2nd intercostal space; a videoscope was inserted through a separate incision within the same interspace. Cardiopulmonary bypass (CPB) was instituted via central arterial and peripheral venous cannulation and an aortotomy was made. The subaortic membrane was resected with shafted instruments. The left ventricular outflow tract was inspected and CPB was weaned. Thirty-day mortality, intensive care and hospital length of stay, ventilation time, operative times, postoperative morbidity, and need for additional procedures were evaluated.

RESULTS

The median CPB and cross-clamp times were 60 and 42 minutes, respectively. The median time to extubation was 3.6 hours. The median intensive care unit and hospital stay were 22 hours and 3 days, respectively. The postoperative left ventricular outflow tract mean gradients decreased significantly (26.5 vs. 9.4 mm Hg, P = 0.001). There were no conversions to sternotomy, perioperative strokes, or 30-day mortality.

CONCLUSIONS

Subaortic membranes can be resected through a mini-thoracotomy approach with excellent clinical results.

The Opportunities and Limitations of Minimally Invasive Cardiac Surgery

BACKGROUND

Over the past two decades, minimally invasive techniques for classic heart valve surgery and isolated bypass surgery have been developed that enable access to the heart via partial sternotomy for most aortic valve procedures and via sternotomy-free mini-thoracotomy for other procedures.

METHODS

We review the current evidence on minimally invasive cardiac surgery on the basis of pertinent randomized studies and database studies retrieved by a selective search in the MEDLINE and PubMed Central databases, as well as by the Google Scholar search engine.

RESULTS

A PubMed search employing the search term "minimally invasive cardiac surgery" yielded nearly 10 000 hits, among which there were 7 prospective, randomized, controlled trials (RCTs) on aortic valve replacement, with a total of 477 patients, and 3 RCTs on mitral valve surgery, with a total of 340 patients. Only limited reports of specified centers are currently available for multiple valvular procedures and multiple coronary artery bypass procedures. The RCTs reveal that the minimally invasive techniques are associated with fewer wound infections and faster mobilization, without any difference in survival. Minimally invasive procedures are technically demanding and have certain anatomical prerequisites, such as appropriate coronary morphology for multiple bypass operations and the position of the aorta in the chest for sternotomy-free aortic valve procedures. The articles reviewed here were presumably affected by selection bias, in that patients in the published studies were preselected, and there may have been negative studies that were not published at all.

CONCLUSION

Specialized surgeons and centers can now carry out many cardiac valvular and bypass operations via minithoracotomy rather than sternotomy. According to current evidence, these minimally invasive techniques yield results that are at least as good as classic open-heart surgery.

Right thoracotomy for aortic valve replacement in the adolescents with bicuspid aortic valve

BACKGROUND

In this study, we compared our experience about early and midterm follow-up outcomes for right anterolateral minithoracotomy (RAMT) vs full sternotomy (FS) in surgical aortic valve replacement (AVR) among adolescents with bicuspid aortic valve (BAV).

METHODS

Patients were retrospectively enrolled from January 2008 to December 2017. Inclusion criteria were patients with BAV who had to undergo to AVR. They were divided in two groups: RAMT and FS. The choice of RAMT was based on individual surgeon's preferences or when expressly requested by patient that was informed of nonconventional approach.

RESULTS

We enrolled 61 patients, 23 in RAMT group and 38 in FS group. The mean age was 15.6 ± 1.7 years for RAMT group and 16.1 ± 1.5 years for FS group (P = .23). The RAMT group had a higher prevalence of female gender (P = .04). The patients in the RAMT group had longer cardiopulmonary bypass (115.2 ± 18.5 vs 102.2 ± 16.5 min; P = .006) and cross-clamp time (78.6 ± 18.1 vs 74.3 ± 15.2 min; P = .01). No patients required intraoperative conversion to FS. No differences were found in ventilation times, postoperative intensive care unit (ICU), and hospital length of stay for both groups. Follow-up echocardiograms were available for all patients at median of 5.2 years (range 0.5-9.6 years, median 5.4 years for RAMT and 5.1 for FS) and no patient required reoperation for aortic prosthesis malfunction.

CONCLUSIONS

Our study shows that RAMT is safe and effective as FS. Although the RAMT operation takes slightly more operation time, it is not associated with major adverse effects.

A computed tomography-based planning tool for predicting difficulty of minimally invasive aortic valve replacement

OBJECTIVES

Minimally invasive aortic valve replacement has proven its value over the last decade by its significant advancement and reduction in mortality, morbidity and admission time. However, minimally invasive aortic valve replacement is associated with some on-site difficulties such as limited aortic annulus exposure. Currently, computed tomography scans are used to evaluate the anatomical relationship among the intercostal spaces, ascending aorta and aortic valve prior to surgery. We hypothesized that quantitative measurements of access distance and access angle are associated with outcome and access difficulty.

METHODS

We introduce a novel minimally invasive aortic valve replacement planning prototype that allows automatic measurements of access angle, access distance and aortic annulus dimensions. The prototype visualizes these measurements on the chest cage as ISO contours. The association of these measures with outcome parameters such as extracorporeal circulation time, aortic cross-clamping time and access difficulty score was assessed. We included 14 patients who received a new valve by ministernotomy.

RESULTS

The mean access angle was 40.3 ± 5.1°. It was strongly associated with aortic cross-clamping time (Pearson correlation coefficient = 0.60, P = 0.02) and access difficulty score (Spearman's rank correlation coefficient = 0.57, P = 0.03). Access angles were significantly different between easy and difficult access groups (P = 0.03). There was no significant association between access distance and outcome parameters.

CONCLUSIONS

Access angle is strongly associated with procedure complexity. The automated presentation of this measure suggests added value of the prototype in clinical practice.

Minimally invasive aortic valve replacement through a right anterolateral mini-thoracotomy for the treatment of octogenarians with aortic valve stenosis

Because of concerns about the high risk of perioperative complications, the feasibility of minimally invasive aortic valve replacement (MIAVR) for elderly patients remains controversial. Here, we review our results of MIAVR in octogenarians with aortic valve stenosis (AS). Between October 2012 and December 2017, 110 patients with AS underwent MIAVR via a right anterolateral mini-thoracotomy; 41 patients were octogenarian (Group O). The perioperative outcomes of these patients were compared with those of the 69 patients who were less than 80 years of age (Group Y). A preoperative contrast-enhanced computed tomography (CT) scan was performed in all patients to guide the patient selection and aid the decision regarding cannulation sites. Among all cases of isolated aortic valve replacement, MIAVR accounted for 47% cases during this study period. The mean age of Group O was 83.6 ± 2.9 years, with a maximum age of 89. In Group O, there were no in-hospital deaths or morbidity, including stroke. The rate of blood transfusion was significantly higher in Group O than in Group Y (P = 0.01). However, there was no significant difference in ventilation time, the length of intensive care unit stay, the length of hospital stay, or in the rates of cumulative survival and freedom from valve-related complications. With careful patient selection and a perfusion strategy based on preoperative CT scan, equivalent outcomes of MIAVR were even achieved in octogenarians.

Right Mini-thoracotomy Bentall Procedure

Objective

Bentall procedures are traditionally performed through a median sternotomy. The right mini-thoracotomy approach is increasingly used in aortic valve replacement. This approach has been shown to have decreased blood loss and hospital length of stay compared with sternotomy. A right mini-thoracotomy approach may also be beneficial in selected patients requiring aortic root surgery. We present our initial clinical experience of patients who have undergone a right mini-thoracotomy Bentall.

Methods

This is a single-center retrospective review of seven patients who underwent a primary elective right anterior mini-thoracotomy Bentall. A thoracoscope was used in each case. Automated suturing technology was used for annular suturing in three of the seven patients. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital length of stay, time to extubation, operative times, as well as postoperative sequelae including stroke, infection, and bleeding.

Results

Median cardiopulmonary bypass, cross-clamp, and circulatory arrest time were 217, 153, and 28 minutes, respectively. Median time to extubation was 10 hours and median intensive care unit and hospital stay was 1 and 4 days, respectively. One patient had a wound infection and one returned to the operating room for bleeding. There were no in-hospital or 30-day mortalities.

Conclusions

The Bentall procedure can be performed through a right anterior mini-thoracotomy in selected patients with excellent clinical results.

Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference?

BACKGROUND

This study compared perioperative results and mortality rates of different approaches to perform aortic valve replacement (AVR), describing predictors favoring one approach over the others.

METHODS

All patients who underwent AVR were enrolled. The choice of the approach was left to surgeon's preference. Data were retrospectively collected, and the major baseline characteristics (including age, sex, body mass index, creatinine clearance, preoperative condition, cardiovascular risk factors, functional status, and left ventricular ejection fraction, etc.) and intraoperative variables were recorded. To adjust for differences in baseline characteristics between the study groups, a propensity score matching was performed. Linear and logistic regression analyses were performed.

RESULTS

Partial upper hemisternotomy was performed in 820 patients (43%), right anterior minithoracotomy in 488 (26%), and median sternotomy in 599 (31%). After propensity score matching, three groups of 377 patients were obtained. Cardiopulmonary bypass and cross-clamp times were shorter in the right anterior minithoracotomy group than in the median sternotomy and partial upper hemisternotomy groups (p < 0.001). No significant differences in in-hospital mortality were observed (p = 0.9). Renal failure (odds ratio, 5.4; 95% confidence interval, 2.3 to 11.4; p < 0.0001), extracardiac arteriopathy (odds ratio, 2.9; 95% confidence interval, 1.1 to 6.7; p = 0.017), and left ventricular ejection fraction (odds ratio, 0.96; 95% confidence interval, 0.93 to 0.99; p = 0.009) emerged as independent predictors of in-hospital mortality.

CONCLUSIONS

Minimal-access isolated aortic valve surgery is a reproducible, safe, and effective procedure with similar outcomes and operating times compared with conventional sternotomy.