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Papadopoulos N, Ntinopoulos V, Haeussler A, Odavic D, Risteski P, Biefer HRC, Dzemali O. Less invasive replacement of aortic root, ascending aorta and hemiarch via partial upper sternotomy: a propensity-score-matched comparison with full sternotomy. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 39:ivae120. [PMID: 38941507 PMCID: PMC11254289 DOI: 10.1093/icvts/ivae120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 06/07/2024] [Accepted: 06/27/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVES Less invasive surgery has emerged as an option for aortic pathologies. The current study compared our experience on early postoperative results of patients with aortic surgery between partial upper sternotomy (PUS) and full sternotomy (FS). METHODS We performed a retrospective analysis of the data of patients undergoing aortic root surgery with concomitant ascending aorta and hemiarch replacement. Exclusion criteria were type A aortic dissection and other concomitant major cardiac surgery. After propensity score matching, we compared the perioperative outcomes of patients undergoing surgery with PUS versus FS. RESULTS A total of 161 patients operated on between January 2013 and September 2022 met the inclusion criteria (PUS: n = 22, FS: n = 139). Propensity score matching yielded 22 pairs with a balanced distribution of propensity scores and covariates between the compared groups. There was no evidence that PUS affects cardiopulmonary bypass [108 (67-119) vs 113 (87-148) min, P = 0.154; PUS vs FS] and circulatory arrest duration [9 (7-10) vs 9 (8-13) min, P = 0.264; PUS vs FS]. There was a reduced cross-clamp duration in the PUS group [88 (58-96) vs 92 (71-122) min, P = 0.032]. Cumulative sum charts have shown consistently low cross-clamp and circulatory arrest duration for 2 experienced surgeons who performed 20 of the procedures in the PUS group (10 each). Perioperative mortality and morbidity were low, with no in-hospital mortality in the PUS group [0 vs 1(4.5%), P > 0.999] and absence of strokes in both groups. CONCLUSIONS In summary, our initial experience suggests that less invasive aortic root, ascending aorta and hemiarch replacement via PUS could be performed in our patient cohort as safely as via full sternotomy. Advantages for the patient are reduced surgical trauma, improved cosmetic results and-presumably-less pain.
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Affiliation(s)
- Nestoras Papadopoulos
- Department of Cardiac Surgery, Municipal Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Vasileios Ntinopoulos
- Department of Cardiac Surgery, Municipal Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Achim Haeussler
- Department of Cardiac Surgery, Municipal Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Dragan Odavic
- Department of Cardiac Surgery, Municipal Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Petar Risteski
- Department of Cardiac Surgery, Municipal Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Héctor Rodríguez Cetina Biefer
- Department of Cardiac Surgery, Municipal Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, Municipal Hospital of Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital of Zurich, University of Zurich, Zurich, Switzerland
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Abubokha AOK, Li R, Li CH, Zalloom AM, Wei X. Early Outcomes of Minimally Invasive Right Anterior Thoracotomy vs. Median Full Sternotomy in Isolated Aortic Valve Replacement: A Propensity Score Analysis. Braz J Cardiovasc Surg 2024; 39:e20230108. [PMID: 38569069 PMCID: PMC10989319 DOI: 10.21470/1678-9741-2023-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 07/19/2023] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION This study aimed to compare the early postoperative outcomes of right anterior thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery with those of median full sternotomy aortic valve replacement (MFS-AVR) approach with the goal of identifying potential benefits or drawbacks of each technique. METHODS This retrospective, observational, cohort study included 476 patients who underwent RAT-MIAVR or MFS-AVR in our hospital from January 2015 to January 2023. Of these, 107 patients (22.5%) underwent RAT-MIAVR, and 369 patients (77.5%) underwent MFS-AVR. Propensity score matching was used to minimize selection bias, resulting in 95 patients per group for analysis. RESULTS After propensity matching, two groups were comparable in preoperative characteristics. RAT-MIAVR group showed longer cardiopulmonary bypass time (130.24 ± 31.15 vs. 117.75 ± 36.29 minutes, P=0.012), aortic cross-clamping time (76.44 ± 18.00 vs. 68.49 ± 19.64 minutes, P=0.004), and longer operative time than MFS-AVR group (358.47 ± 67.11 minutes vs. 322.42 ± 63.84 minutes, P=0.000). RAT-MIAVR was associated with decreased hospitalization time after surgery, lower postoperative blood loss and drainage fluid, a reduced incidence of mediastinitis, increased left ventricular ejection fraction, and lower pacemaker use compared to MFS-AVR. However, there was no significant difference in the incidence of major complications and in-hospital mortality between the two groups. CONCLUSION RAT-MIAVR is a feasible and safe alternative procedure to MFS-AVR, with comparable in-hospital mortality and early follow-up. This minimally invasive approach may be a suitable option for patients requiring isolated aortic valve replacement.
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Affiliation(s)
- Anas O. Kh. Abubokha
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei,
People’s Republic of China
| | - Rui Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei,
People’s Republic of China
| | - Chen-he Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei,
People’s Republic of China
| | - Ahmad M. Zalloom
- Tongji Medical College, Huazhong University of Science and
Technology, Wuhan, People’s Republic of China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei,
People’s Republic of China
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3
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Kirmani BH, Jones SG, Muir A, Malaisrie SC, Chung DA, Williams RJ, Akowuah E. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev 2023; 12:CD011793. [PMID: 38054555 PMCID: PMC10698838 DOI: 10.1002/14651858.cd011793.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Aortic valve disease is a common condition easily treatable with cardiac surgery. This is conventionally performed by opening the sternum ('median sternotomy') and replacing the valve under cardiopulmonary bypass. Median sternotomy is well tolerated, but as less invasive options become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access have raised safety concerns with regard to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity. This is an update of a Cochrane review first published in 2017, with seven new studies. OBJECTIVES To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement. SEARCH METHODS We performed searches of CENTRAL, MEDLINE and Embase from inception to August 2021, with no language limitations. We also searched two clinical trials registries and manufacturers' websites. We reviewed references of primary studies to identify any further studies of relevance. SELECTION CRITERIA We included randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, transapical, transfemoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. We determined the certainty of evidence using the GRADE methodology and summarised results of patient-relevant outcomes in a summary of findings table. MAIN RESULTS The review included 14 trials with 1395 participants. Most studies had at least two domains at high risk of bias. We analysed 14 outcomes investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy. Upper hemi-sternotomy may have little to no effect on mortality versus full median sternotomy (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.45 to 1.94; 10 studies, 985 participants; low-certainty evidence). Upper hemi-sternotomy for aortic valve replacement may increase cardiopulmonary bypass time slightly, although the evidence is very uncertain (mean difference (MD) 10.63 minutes, 95% CI 3.39 to 17.88; 10 studies, 1043 participants; very low-certainty evidence) and may increase aortic cross-clamp time slightly (MD 6.07 minutes, 95% CI 0.79 to 11.35; 12 studies, 1235 participants; very low-certainty evidence), although the evidence is very uncertain. Most studies had at least two domains at high risk of bias. Postoperative blood loss was probably lower in the upper hemi-sternotomy group (MD -153 mL, 95% CI -246 to -60; 8 studies, 767 participants; moderate-certainty evidence). Low-certainty evidence suggested that there may be no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.19, 95% CI -0.43 to 0.04; 5 studies, 649 participants). Upper hemi-sternotomy may result in little to no difference in quality of life (MD 0.03 higher, 95% CI 0 to 0.06 higher; 4 studies, 624 participants; low-certainty evidence). Two studies reporting index admission costs concluded that limited sternotomy may be more costly at index admission in the UK National Health Service (MD 1190 GBP more, 95% CI 420 GBP to 1970 GBP, 2 studies, 492 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence was of very low to moderate certainty. Sample sizes were small and underpowered to demonstrate differences in some outcomes. Clinical heterogeneity was also noted. Considering these limitations, there may be little to no effect on mortality. Differences in extracorporeal support times are uncertain, comparing upper hemi-sternotomy to full sternotomy for aortic valve replacement. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from also performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality of life analyses to be included as end points, as well as quantitative measures of physiological reserve.
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Affiliation(s)
- Bilal H Kirmani
- Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Sion G Jones
- Department of Cardiac Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Andrew Muir
- Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University, Chicago, IL, USA
| | | | | | - Enoch Akowuah
- Academic Cardiovascular Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
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Kirmani BH, Akowuah E. Minimal Access Aortic Valve Surgery. J Cardiovasc Dev Dis 2023; 10:281. [PMID: 37504537 PMCID: PMC10380690 DOI: 10.3390/jcdd10070281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Minimally invasive approaches to the aortic valve have been described since 1993, with great hopes that they would become universal and facilitate day-case cardiac surgery. The literature has shown that these procedures can be undertaken with equivalent mortality rates, similar operative times, comparable costs, and some benefits regarding hospital length of stay. The competing efforts of transcatheter aortic valve implantation for these same outcomes have provided an excellent range of treatment options for patients from cardiology teams. We describe the current state of the art, including technical considerations, caveats, and complications of minimal access aortic surgery and predict future directions in this space.
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Affiliation(s)
- Bilal H Kirmani
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Enoch Akowuah
- Cardiac Surgery, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough TS4 3BW, UK
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Almeida AS, Ceron RO, Anschau F, de Oliveira JB, Leão Neto TC, Rode J, Rey RAW, Lira KB, Delvaux RS, de Souza RORR. Conventional Versus Minimally Invasive Aortic Valve Replacement Surgery: A Systematic Review, Meta-Analysis, and Meta-Regression. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:3-13. [PMID: 35044253 DOI: 10.1177/15569845211060039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: To assess the potential benefits of minimally invasive aortic valve replacement (MIAVR) compared with conventional AVR (CAVR) by examining short-term outcomes. Methods: A systematic search identified randomized trials comparing MIAVR with CAVR. To assess study limitations and quality of evidence, we used the Cochrane Risk of Bias tool and GRADE and performed random-effects meta-analysis. We used meta-regression and sensitivity analysis to explore reasons for diversity. Results: Thirteen studies (1,303 patients) were included. For the comparison of MIAVR and CAVR, the risk of bias was judged low or unclear and the quality of evidence ranged from very low to moderate. No significant difference was observed in mortality, stroke, acute kidney failure, infectious outcomes, cardiac events, intubation time, intensive care unit stay, reoperation for bleeding, and blood transfusions. Blood loss (mean difference [MD] = -130.58 mL, 95% confidence interval [CI] = -216.34 to -44.82, I2 = 89%) and hospital stay (MD = -0.93 days, 95% CI = -1.62 to -0.23, I2 = 81%) were lower with MIAVR. There were shorter aortic cross-clamp (MD = 5.99 min, 95% CI = 0.99 to 10.98, I2 = 93%) and cardiopulmonary bypass (CPB) times (MD = 7.75 min, 95% CI = 0.27 to 15.24, I2 = 94%) in the CAVR group. In meta-regression analysis, we found that age was the variable with the greatest influence on heterogeneity. Conclusions: MIAVR seems to be an excellent alternative to CAVR, reducing hospital stay and incidence of hemorrhagic events. Despite significantly greater aortic cross-clamp and CPB times with MIAVR, this did not translate into adverse effects, with no changes in the results found with CAVR.
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Affiliation(s)
- Adriana Silveira Almeida
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Health Technology Assessment Center (NATS), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rafael Oliveira Ceron
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Fernando Anschau
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Health Technology Assessment Center (NATS), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Postgraduate Program in Technology Assessment for SUS (PPGATSUS/GHC), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Jeffchandler Belém de Oliveira
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
| | - Tércio Campos Leão Neto
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
| | - Juarez Rode
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rafael Antonio Widholzer Rey
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Kathize Betti Lira
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Renan Senandes Delvaux
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rodrigo Oliveira Rosa Ribeiro de Souza
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
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6
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Zallé I, Son M, El-Alaoui M, Nijimbéré M, Boumzebra D. Minimally invasive and full sternotomy in aortic valve replacement: a comparative early operative outcomes. Pan Afr Med J 2021; 40:68. [PMID: 34804336 PMCID: PMC8590260 DOI: 10.11604/pamj.2021.40.68.28008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction aortic valve replacement is usually performed through a median full sternotomy (MFS) in our department. Minimally invasive aortic valve replacement (MIAVR) has been recently adopted as a new approach. According to the literature, the superiority of MIAVR is controversial. In this study we report early post-operative outcomes in MIAVR compared with MFS access with reference to blood Loss, wound infections, post-operative recovery, morbidity and mortality. Methods this study was a prospective data collection from 36 consecutive patients undergoing isolated valve replacement. Two population study was identified, MIAVR group (group I n=18) and MFS group (group II n=18). Patients´ data were collected and analyzed using IBM SPSS statistics 21 software and Khi2 test has been used to compare the variables. The study variables are presented as numbers, percentage, median with interquartile range. Pre-operative planning was performed so that to obtain similar characteristics. Results in group I, upper mini-sternotomy was used in 12 patients and right mini-thoracotomy in 6 patients. There was no difference in term of mortality and morbidity. MIAVR was associated with longer CPB time (93.25 (58-161) vs 131 (75-215) mins, P=0.047) with no significant difference in term of ACC time (81 (33-162) vs 58.8 (59-102) mins P=0.158). MIAVR´ Patients had likely lower incidence of red blood cells transfusion (16.7 vs 52.3%) without significant difference about post-operative haemoglobin (P = 0,330). Patients in group I had shorter ventilation time (2.35 (1-12) vs 9.3 (1-48) hours P < 0.01), shorter ICU stay (2.44 (1-8) vs 4.25 (1-9) days, P = 0,024). The length of hospital stay was shorter, 6.5 (5-9) days in group I vs 7.4 (6-11), P=0.0274. Length of chest tube stay was shorter in group I (mean 1.53 vs 2.4 days, P=0,033). Wound infections were not found in both groups. Conclusion minimally invasive aortic valve replacement is associated with less blood loss, faster post-operative recovery faster post-operative recovery but increase operation time.
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Affiliation(s)
- Issaka Zallé
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Moussa Son
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Mohamed El-Alaoui
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Macédoine Nijimbéré
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Drissi Boumzebra
- Cardiovascular Surgery Department, Mohammed VI University Hospital, Marrakech, Morocco
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7
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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Expertise-based design in surgical trials: a narrative review. Can J Surg 2021; 64:E594-E602. [PMID: 34759044 PMCID: PMC8592777 DOI: 10.1503/cjs.008520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
Randomized controlled trials (RCTs) are the most robust study design for evaluating the safety and efficacy of a therapeutic intervention. However, their internal validity are at risk when evaluating surgical interventions. This review summarizes existing expertise- based trials in surgery and related methodological concepts to guide surgeons performing this work. We provide caseloads required to reach the learning curve for various surgical interventions and report criteria for expertise from published and unpublished expertise-based trials. In addition, we review design and implementation concepts of expertise-based trials, including recruitment of surgeons, crossover, ethics, generalizability, sample size and definitions for learning curve. Several RCTs have used an expertise-based design. We found that the majority of definitions used for expertise were vague, heterogeneous, and inconsistent across trials evaluating the same surgical intervention. Statistical methods exist to adjust for the learning curve; however, there is limited guidance. We developed the following criteria for surgical expertise for future trials: 1) decide on the proxy to be used for the learning curve, and 2) assess eligible surgeons by comparing their performance to the previously defined expertise criteria.
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Affiliation(s)
- Ali Alsagheir
- From the Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ont. (Alsagheir, Whitlock); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Kozirarz); the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ont. (Belley-Côté, Whitlock); and the Department of Medicine, McMaster University, Hamilton, Ont. (Belley-Côté)
| | - Alex Koziarz
- From the Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ont. (Alsagheir, Whitlock); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Kozirarz); the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ont. (Belley-Côté, Whitlock); and the Department of Medicine, McMaster University, Hamilton, Ont. (Belley-Côté)
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Mohamed MA, Ding S, Ali Shah SZ, Li R, Dirie NI, Cheng C, Wei X. Comparative Evaluation of the Incidence of Postoperative Pulmonary Complications After Minimally Invasive Valve Surgery vs. Full Sternotomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Propensity Score-Matched Studies. Front Cardiovasc Med 2021; 8:724178. [PMID: 34497838 PMCID: PMC8419439 DOI: 10.3389/fcvm.2021.724178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/27/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Postoperative pulmonary complications remain a leading cause of increased morbidity, mortality, longer hospital stays, and increased costs after cardiac surgery; therefore, our study aims to analyze whether minimally invasive valve surgery (MIVS) for both aortic and mitral valves can improve pulmonary function and reduce the incidence of postoperative pulmonary complications when compared with the full median sternotomy (FS) approach. Methods: A comprehensive systematic literature research was performed for studies comparing MIVS and FS up to February 2021. Randomized controlled trials (RCTs) and propensity score-matching (PSM) studies comparing early respiratory function and pulmonary complications after MIVS and FS were extracted and analyzed. Secondary outcomes included intra- and postoperative outcomes. Results: A total of 10,194 patients from 30 studies (6 RCTs and 24 PSM studies) were analyzed. Early mortality differed significantly between the groups (MIVS 1.2 vs. FS 1.9%; p = 0.005). Compared with FS, MIVS significantly lowered the incidence of postoperative pulmonary complications (odds ratio 0.79, 95% confidence interval [0.67, 0.93]; p = 0.004) and improved early postoperative respiratory function status (mean difference -24.83 [-29.90, -19.76]; p < 0.00001). Blood transfusion amount was significantly lower after MIVS (p < 0.02), whereas cardiopulmonary bypass time and aortic cross-clamp time were significantly longer after MIVS (p < 0.00001). Conclusions: Our study showed that minimally invasive valve surgery decreases the incidence of postoperative pulmonary complications and improves postoperative respiratory function status.
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Affiliation(s)
- Mohamed Abdulkadir Mohamed
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Ding
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sayed Zulfiqar Ali Shah
- Department of Rehabilitation Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Department of Rehabilitation Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Najib Isse Dirie
- Division of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cai Cheng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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9
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Torky MA, Arafat AA, Fawzy HF, Taha AM, Wahby EA, Herijgers P. J-ministernotomy for aortic valve replacement: a retrospective cohort study. THE CARDIOTHORACIC SURGEON 2021. [DOI: 10.1186/s43057-021-00050-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The advantage of minimally invasive sternotomy (MS) over full sternotomy (FS) for isolated aortic valve replacement (AVR) is still controversial. We aimed to examine if J-shaped MS is a safe alternative to FS in patients undergoing primary isolated AVR. This study is a retrospective and restricted cohort study that included 137 patients who had primary isolated AVR from February 2013 to June 2015. Patients with previous cardiac operations, low ejection fraction (< 40%), infective endocarditis, EuroSCORE II predicted mortality > 10%, and patients who had inverted T or inverted C-MS or right anterior thoracotomy were excluded. Patients were grouped into the FS group (n=65) and MS group (n=72). Preoperative variables were comparable in both groups. The outcome was studied, balancing the groups by propensity score matching.
Results
Seven (9%) patients in the MS group were converted to FS. Cardiopulmonary bypass (98.5 ± 29.3 vs. 82.1 ± 13.95 min; p ≤ 0.001) and ischemic times (69.1 ± 23.8 vs. 59.6 ± 12.2 min; p = 0.001) were longer in MS. The MS group had a shorter duration of mechanical ventilation (10.1 ± 11.58 vs. 10.9 ± 6.43 h; p = 0.045), ICU stay (42.74 ± 40.5 vs. 44.9 ± 39.3; p = 0.01), less chest tube drainage (385.3 ± 248.6 vs. 635.9 ± 409.6 ml; p = 0.001), and lower narcotics use (25.14 ± 17.84 vs. 48.23 ± 125.68 mg; p < 0.001). No difference was found in postoperative heart block with permanent pacemaker insertion or atrial fibrillation between groups (p = 0.16 and 0.226, respectively). Stroke, renal failure, and mortality did not differ between the groups. Reintervention-free survival at 1, 3, and 4 years was not significantly different in both groups (p = 0.73).
Conclusion
J-ministernotomy could be a safe alternative to FS in isolated primary AVR. Besides the cosmetic advantage, it could have better clinical outcomes without added risk.
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10
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Abstract
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.
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Affiliation(s)
- Lorenzo Di Bacco
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
| | - Antonio Miceli
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
| | - Mattia Glauber
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
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11
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Klop ID, van Putte BP, Kloppenburg GT, Sprangers MA, Nieuwkerk PT, Klein P. Comparing quality of life and postoperative pain after limited access and conventional aortic valve replacement: Design and rationale of the LImited access aortic valve replacement (LIAR) trial. Contemp Clin Trials Commun 2021; 21:100700. [PMID: 33506139 PMCID: PMC7815656 DOI: 10.1016/j.conctc.2021.100700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/04/2020] [Accepted: 01/01/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Surgical aortic valve replacement (SAVR) via limited access approaches ('mini-AVR') have proven to be safe alternative for the surgical treatment of aortic valve disease. However, it remains unclear whether these less invasive approaches are associated with improved quality of life and/or reduced postoperative pain when compared to conventional SAVR via full median sternotomy (FMS). STUDY DESIGN The LImited access Aortic valve Replacement (LIAR) trial is a single-center, single blind randomized controlled clinical trial comparing 2 arms of 80 patients undergoing limited access SAVR via J-shaped upper hemi-sternotomy (UHS) or conventional SAVR through FMS. In all randomized patients, the diseased native aortic valve is planned to be replaced with a rapid deployment stented bioprosthesis. Patients unwilling or unable to participate in the randomized trial will be treated conventionally via SAVR via FMS and with implantation of a sutured valve prosthesis. These patients will participate in a prospective registry. STUDY METHODS Primary outcome is improvement in cardiac-specific quality of life, measured by two domains of the Kansas City Cardiomyopathy Questionnaire up to one year after surgery. Secondary outcomes include, but are not limited to: generic quality of life measured with the Short Form-36, postoperative pain, perioperative (technical success rate, operating time) and postoperative outcomes (30-day and one-year mortality), complication rate and hospital length of stay. CONCLUSION The LIAR trial is designed to determine whether a limited access approach for SAVR ('mini-AVR') is associated with improved quality of life and/or reduced postoperative pain compared with conventional SAVR through FMS.The study is registered at ClinicalTrials.gov, number NCT04012060.
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Affiliation(s)
- Idserd D.G. Klop
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Bart P. van Putte
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiothoracic Surgery, AMC Heart Centre, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Mirjam A.G. Sprangers
- Department of Medical Psychology, Amsterdam University Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Amsterdam University Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Patrick Klein
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
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12
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Rodríguez-Caulo EA, Guijarro-Contreras A, Guzón A, Otero-Forero J, Mataró MJ, Sánchez-Espín G, Porras C, Villaescusa JM, Melero-Tejedor JM, Jiménez-Navarro M. Quality of Life After Ministernotomy Versus Full Sternotomy Aortic Valve Replacement. Semin Thorac Cardiovasc Surg 2020; 33:328-334. [PMID: 32853740 DOI: 10.1053/j.semtcvs.2020.07.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/17/2020] [Indexed: 12/27/2022]
Abstract
Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomized trials. The QUALITY-AVR trial is a single-blind, single-center, independent, randomized clinical trial comparing ministernotomy to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients were randomized in a 1:1 computational fashion. The primary endpoint was a difference between intervention groups of ≥0.10 points in change from baseline quality of life Questionnaire EuroQOL-index, measured at 1, 6, or 12 months. Secondary endpoints were differences in change from other baseline EuroQOL-index utilities, cardiac surgery-specific satisfaction questionnaire (SATISCORE), a combined safety endpoint of 4 major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events, and acute renal failure), bleeding through drains within the first 24 hours, intubation time, and other minor endpoints. Clinical follow-up was scheduled at baseline, 1, 6, and 12 months after randomization. Change from baseline mean difference EQ-5D-index was +0.20 points (95% confidence interval 0.10-0.30, P < 0.001) and median difference +0.14 (95% confidence interval 0.06-0.22, P < 0.001), favoring the ministernotomy group at 1 month. Patient satisfaction was also better at 1 month (Satiscore 83 ± 9 vs 77 ± 13 points; P = 0.010). The ministernotomy group had significantly less bleeding in the first 24 hours (299 ± 140 vs 509 ± 251 mL, P = 0.001). Ministernotomy provides a faster recovery with improved quality of life and satisfaction at 1 month compared to full sternotomy.
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Affiliation(s)
- Emiliano A Rodríguez-Caulo
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Guijarro-Contreras
- UGC Heart Area, Cardiology Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Arantza Guzón
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Otero-Forero
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - María José Mataró
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Sánchez-Espín
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Porras
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - José M Villaescusa
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - José María Melero-Tejedor
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Jiménez-Navarro
- UGC Heart Area, Cardiology Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
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13
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Shneider YA, Tsoi MD, Fomenko MS, Pavlov AA, Shilenko PA. [Aortic valve replacement via J-shaped partial upper sternotomy: randomized trial, mid-term results]. Khirurgiia (Mosk) 2020:25-30. [PMID: 32736460 DOI: 10.17116/hirurgia202007125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of aortic valve replacement through upper partial J-shaped sternotomy compared to conventional sternotomy. MATERIAL AND METHODS There were 240 procedures of isolated aortic valve replacement for the period 2012-2017. According to inclusion criteria, 112 patients were randomized into 2 groups: group I - median sternotomy, group II - upper partial J-shaped sternotomy. Mean age of patients was 56.1±14.3 and 53.1±14.9 years, respectively (p=0.284). Females prevailed in both groups (55.4% vs. 57.1%, p=0.848). Peak pressure gradient on the aortic valve was 106.2±23.9 and 102.8±25.3 mm Hg, respectively (p=0.484). RESULTS In-hospital mortality was 1.8% (n=1) in group I (p=0.315). Incidence of postoperative complications (complete atrioventricular blockade, ventricular septal defect) was similar (p=1.0). Mean time cross clamping in I and II groups was 65.5±12.5 and 64.7±13.1 min (p=0.729). Mean follow-up period was 31.6 and 33.5 months, respectively. Kaplan-Meier survival rate was 92.6 and 93.0%, respectively (log-rank test=0,767). Freedom from thromboembolic events was 91.7 and 90% (log-rank test=0.213). CONCLUSION. U Pper partial J-shaped sternotomy is safe and effective for aortic valve surgery and characterized by similar outcomes compared to conventional sternotomy.
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Affiliation(s)
- Yu A Shneider
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - M D Tsoi
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - M S Fomenko
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - A A Pavlov
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
| | - P A Shilenko
- Federal Center for High Medical Technologies of the Ministry of Health, Kaliningrad, Russia
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Solinas M, Bianchi G, Chiaramonti F, Margaryan R, Kallushi E, Gasbarri T, Santarelli F, Murzi M, Farneti P, Leone A, Simeoni S, Varone E, Marchi F, Glauber M, Concistrè G. Right anterior mini-thoracotomy and sutureless valves: the perfect marriage. Ann Cardiothorac Surg 2020; 9:305-313. [PMID: 32832412 DOI: 10.21037/acs-2019-surd-172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background A minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates a MIA. We describe our experience with the sutureless Perceval (LivaNova, Italy) aortic bioprosthesis through a right anterior mini-thoracotomy (RAMT) approach. Methods Between March 2011 and October 2019, 1,049 patients underwent AVR with Perceval bioprosthesis. Five hundred and three patients (48%) were operated through a RAMT approach in the second intercostal space. Considering only isolated AVR (881), 98% of patients were operated with MIA, and Perceval in RAMT approach was performed in 57% of these patients. Eight patients (1.6%) had previously undergone cardiac surgery. The prosthesis sizes implanted were: S (n=91), M (n=154), L (n=218) and XL (n=40). Concomitant procedures were mitral valve surgery (n=6), tricuspid valve repair (n=1), mitral valve repair and tricuspid valve repair (n=1) and miectomy (n=2). Mean age was 78±4 years (range, 65-89 years), 317 patients were female (63%) and EuroSCORE II was 5.9%±8.4%. Results The 30-day mortality was 0.8% (4/503). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were 81.6±30.8 and 50.3±24.5 minutes respectively for stand-alone procedures. In two patients, early moderate paravalvular leakage appeared as a result of incomplete expansion of the sutureless valve due to oversizing of the bioprosthesis, requiring reoperations at two and nine postoperative days with sutured aortic bioprosthesis implantation. Permanent pacemaker implantation within the first thirty days was necessary in 26 (5.2%) patients. At the mean follow-up of 4.6 years (range, 1 month to 8.6 years), survival was 96%, freedom from reoperation was 99.2%, and mean transvalvular pressure gradient was 11.9±4.3 mmHg. Conclusions AVR with the Perceval bioprosthesis in a RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates a RAMT approach.
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Affiliation(s)
- Marco Solinas
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Giacomo Bianchi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Francesca Chiaramonti
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Rafik Margaryan
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Enkel Kallushi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Tommaso Gasbarri
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Filippo Santarelli
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Michele Murzi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Pierandrea Farneti
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Alessandro Leone
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Simone Simeoni
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Egidio Varone
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Federica Marchi
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Mattia Glauber
- Department of Minimally-Invasive Cardiac Surgery, Istituto Clinico Sant' Ambrogio, Milan, Italy
| | - Giovanni Concistrè
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
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15
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Gumus F, Hasde AI, Bermede O, Kilickap M, Durdu MS. Multiple Valve Implantation Through a Minimally Invasive Approach: Comparison of Standard Median Sternotomy and Right Anterior Thoracotomy. Heart Lung Circ 2020; 29:1418-1423. [PMID: 32249168 DOI: 10.1016/j.hlc.2020.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 12/09/2019] [Accepted: 01/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Following developments in the area of minimally invasive surgery and good, recently published surgical results, the areas in which minimally invasive surgery can be used are beginning to expand. This study aimed to describe experience and show the feasibility and safety of minimally invasive multiple valve implantation with right anterior minithoracotomy (RAT) and compare the outcomes with cases that underwent multiple valve surgery via a standard median sternotomy. METHODS The study cohort comprised 52 patients with combined valvular disease who underwent aortic valve replacement and mitral valve replacement or repair, and/or tricuspid valve ring annuloplasty through median sternotomy (control group n=32) or minimally invasive surgery through a RAT (study group n=20) between January 2012 and December 2018 at the current centre. Preoperative evaluation included coronary catheterisation and multisliced computerised tomography in all patients. Postoperative clinical outcomes and haemodynamic performance of heart valves were reviewed. RESULTS The mean age of patients was 72.6±7.1 years, and 50% were male. Seventeen (17) patients (32.6%) were in New York Heart Association functional class III or IV. Three (3) patients (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 21±3.9 months (maximum 26 months). No major paravalvular leakage occurred, and there was no postoperative valve migration in either group. Non-valve-related deaths occurred in five patients during follow-up. CONCLUSION This study showed that minimally invasive multiple valve implantation is a technically feasible and safe procedure with acceptable surgical outcomes and similar postoperative quality when compared with median sternotomy.
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Affiliation(s)
- Fatih Gumus
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Ali Ihsan Hasde
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Onat Bermede
- Department of Anesthesiology and Reanimation, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Kilickap
- Department of Cardiology, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Serkan Durdu
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey.
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Sanad M, Beshir H. Minimally invasive aortic valve replacement with central cannulation: A cost-benefit analysis in a developing country. THE CARDIOTHORACIC SURGEON 2020; 28:9. [PMID: 38624293 PMCID: PMC7222165 DOI: 10.1186/s43057-020-00019-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 02/06/2020] [Indexed: 11/30/2022] Open
Abstract
Background Minimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. However, few centers have started using these approaches with standard equipment because of the limited resources. We sought to report intra- and postoperative clinical outcomes and address health resource utilization after MIAVR. Results A total of 102 eligible patients who had aortic valve replacement were enrolled in a prospective, multicenter cohort study conducted from June 2015 to December 2017. Fifty patients underwent aortic valve surgery via upper inverted T-shaped hemi-sternotomy (MS), and 52 patients were operated using full sternotomy (FS) in two centers in a developing country. Central cannulation was performed in all cases. Major adverse cardiac events, pain, and wound complications were compared. A cost analysis was performed, and exposure and feasibility for cannulation were assessed. The mean length of MS skin incision was 5.82 ± 0.67 cm. Cumulative cross-clamp time was insignificant between both groups (91.87 ± 34.41 versus 94.91 ± 33.96 min; p = 0.66). MS exhibited shorter ventilation time (6.18 ± 1.86 versus 10.68 ± 12.78 h; p = 0.029) and intensive care stays (33.27 ± 19.75 versus 49.42 ± 47.1 h; p = 0.037). Major adverse cardiac events (MACEs) were compared, and MS group exhibited fewer transfusions (1.18 ± 0.89 versus 1.7 ± 0.97 units; p = 0.002), fewer pulmonary complications (1 (2%) versus 2 (3.8%); p < 0.001), and less sternotomy wound infection (1 (2%) versus 5 (9.6%); p = 0.048). Total operative mortality of 4.46% was recorded (n = 5). Significant cost reduction was recorded favoring MS; central cannulation saved $907.16 and carried a total cost reduction of $580 (9.3%) when compared with the FS approach (p < 0.0001). Conclusions With a lack of logistics in developing countries, MIAVR not only has a cosmetic advantage but carries a significant reduction in blood use, respiratory complications, pain, and cost. MIAVR can be feasible, with a rapid learning curve in developing centers.
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Affiliation(s)
- Mohammed Sanad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University Hospitals, D17, F5. 60, El Gomhoria Street, Qism 2, Mansoura, Dakahlia 35516 Egypt
- Department of Cardiothoracic Surgery, Egypt Ministry of Health and Population, Nasser Institute for Research and Treatment, Cairo, Egypt
| | - Hatem Beshir
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University Hospitals, D17, F5. 60, El Gomhoria Street, Qism 2, Mansoura, Dakahlia 35516 Egypt
- Department of Cardiothoracic Surgery, Egypt Ministry of Health and Population, Alexandria Directorate, Alexandria, Egypt
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17
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Maimari M, Baikoussis NG, Gaitanakis S, Dalipi-Triantafillou A, Katsaros A, Kantsos C, Lozos V, Triantafillou K. Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation? Ann Card Anaesth 2020; 23:7-13. [PMID: 31929240 PMCID: PMC7034196 DOI: 10.4103/aca.aca_158_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Maria Maimari
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Nikolaos G Baikoussis
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Stelios Gaitanakis
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | | | - Andreas Katsaros
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Charilaos Kantsos
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
| | - Vasileios Lozos
- Department of Cardiac Surgery, Ippokrateio General Hospital of Athens, Athens, Greece
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El Gamel A. Minimal Access Aortic Root Surgery: An "Elite Sport" or Is it for Everyone? Heart Lung Circ 2019; 28:1767-1769. [PMID: 31813479 DOI: 10.1016/j.hlc.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Adam El Gamel
- Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand; Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; University of Waikato Medical Research Centre, The University of Waikato, New Zealand.
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19
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Bruno P, Cammertoni F, Rosenhek R, Mazza A, Pavone N, Iafrancesco M, Nesta M, Chiariello GA, Spalletta C, Graziano G, Sanesi V, D’Errico D, Massetti M. Improved Patient Recovery With Minimally Invasive Aortic Valve Surgery: A Propensity-Matched Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:419-427. [DOI: 10.1177/1556984519868715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Despite conflicting evidence available, minimally invasive aortic valve replacement (MIAVR) is increasingly used as an alternative to full sternotomy. We sought to compare early outcomes of aortic valve replacement through a full sternotomy (conventional aortic valve replacement [CAVR]) and upper ministernotomy (MIAVR). Methods We analyzed 297 patients having undergone primary, elective, isolated MIAVR or CAVR between January 2014 and June 2018. Following propensity score matching, 120 patients remained in each group. Results MIAVR required longer bypass (93 ± 26 vs 81 ± 24 minutes, P < 0.01) and operative times (214 ± 39 vs 182 ± 37 minutes, P < 0.01). However, aortic cross-clamp times were comparable (57 ± 17 vs 54 ± 14 minutes for MIAVR and CAVR, respectively, P = 0.14). MIAVR had less 24-hour blood loss (253 ± 204 vs 323 ± 296 mL, P = 0.03), less red blood cells transfusions [1.4 packs (1.1 o 1.9) vs 2.1 packs (1.8 to 2.7), P = 0.01], and shorter assisted ventilation time (7.1 ± 3.3 vs 9.7 ± 3.8 hours, P < 0.01) when compared to CAVR. These results led to significantly shorter intensive care unit and hospital stays for MIAVR patients (2.5 ± 1.3 vs 3.4 ± 1.1 days, P < 0.01 and 6.9 ± 4.1 vs 8.2 ± 4.8 days, P = 0.03, respectively). Thirty-day mortality and clinical outcomes did not differ significantly among groups. Conclusions MIAVR through upper ministernotomy was shown to be as safe and reliable as CAVR. Patient recovery time was improved by shortening mechanical ventilation and reducing blood loss and transfusions. These results may be significant for high-risk patients undergoing aortic valve surgery.
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Affiliation(s)
- Piergiorgio Bruno
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Raphael Rosenhek
- Department of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Andrea Mazza
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Natalia Pavone
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Mauro Iafrancesco
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | | | | | | | | | - Denise D’Errico
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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Liang NE, Wisneski AD, Wozniak CJ, Ge L, Tseng EE. Evolution of Minimally Invasive Surgical Aortic Valve Replacement at a Veterans Affairs Medical Center. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:251-262. [PMID: 31081708 DOI: 10.1177/1556984519843498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The majority of minimally invasive surgical aortic valve replacements (MIAVRs) are performed at high-volume cardiac surgery centers. However, outcomes at lower volume federal facilities are not yet reported in the literature and not captured in the national Society of Thoracic Surgeons (STS) database. Our study objective was to describe the evolution of MIAVR at a Veterans Affairs Medical Center (VAMC). METHODS A single-center retrospective cohort study was performed of 114 patients who underwent MIAVR for isolated aortic valvular disease between January 2011 and August 2018. Preoperative STS risk factors were determined and perioperative outcomes were analyzed. RESULTS By 2016, 100% of isolated surgical aortic valve replacements were performed as MIAVRs at our VAMC. Introduction of automatic knot-fastening devices, single-shot del Nido cardioplegia, and rapid deployment valves decreased aortic cross-clamp (AXC) times from a median of 96 (interquartile range [IQR]: 84 to 103) to 53 minutes (38 to 61, P < 0.001, Kruskal-Wallis). Thirty-day mortality was 0.9%. Median length of hospital stay was 9 days (7 to 13). Postoperative atrial fibrillation occurred in 54% of patients, stroke occurred in 1.8% of patients, and 7.1% of patients required permanent pacemakers. Transition to rapid deployment valves decreased postoperative mean pressure gradient from median 14 mmHg (10 to 17) to 7 mmHg (4.7 to 10, P < 0.001, Mann-Whitney). At median 1.5-year follow-up echocardiogram, mean gradient was 10.8 mmHg with mild paravalvular leak rate of 1.8%. CONCLUSIONS Facilitating technologies decreased operative times during MIAVR adoption at our VAMC. For patients with isolated aortic valve pathology, MIAVR can be performed with low morbidity and mortality at lower volume federal institutions, with outcomes comparable to those reported from higher volume centers.
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Affiliation(s)
- Norah E Liang
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Andrew D Wisneski
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Curtis J Wozniak
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Liang Ge
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Elaine E Tseng
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
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Vukovic PM, Milojevic P, Stojanovic I, Micovic S, Zivkovic I, Peric M, Milicic M, Milacic P, Milojevic M, Bojic M. The role of ministernotomy in aortic valve surgery—A prospective randomized study. J Card Surg 2019; 34:435-439. [DOI: 10.1111/jocs.14053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/31/2019] [Accepted: 04/02/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Petar M. Vukovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Predrag Milojevic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Ivan Stojanovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Slobodan Micovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Igor Zivkovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Miodrag Peric
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Miroslav Milicic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Petar Milacic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Milan Milojevic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Milovan Bojic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
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Jahangiri M, Hussain A, Akowuah E. Minimally invasive surgical aortic valve replacement. Heart 2019; 105:s10-s15. [DOI: 10.1136/heartjnl-2018-313512] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/12/2018] [Accepted: 10/16/2018] [Indexed: 11/03/2022] Open
Abstract
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.
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Doenst T, Diab M, Sponholz C, Bauer M, Färber G. The Opportunities and Limitations of Minimally Invasive Cardiac Surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:777-784. [PMID: 29229038 DOI: 10.3238/arztebl.2017.0777] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 04/05/2017] [Accepted: 09/13/2017] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller Universität Jena; Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller Universität Jena
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Minimally invasive aortic valve replacement: is the effort justified? Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-017-0640-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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25
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Rodríguez-Caulo EA, Guijarro-Contreras A, Otero-Forero J, Mataró MJ, Sánchez-Espín G, Guzón A, Porras C, Such M, Ordóñez A, Melero-Tejedor JM, Jiménez-Navarro M. Quality of life, satisfaction and outcomes after ministernotomy versus full sternotomy isolated aortic valve replacement (QUALITY-AVR): study protocol for a randomised controlled trial. Trials 2018; 19:114. [PMID: 29454380 PMCID: PMC5816540 DOI: 10.1186/s13063-018-2486-x] [Citation(s) in RCA: 6] [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: 05/22/2017] [Accepted: 01/19/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND During the last decade, the use of ministernotomy in cardiac surgery has increased. Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomised trials. The aim of the study is to determine if this minimally invasive approach improves quality of life, satisfaction and clinical morbimortality outcomes. METHODS/DESIGN The QUALITY-AVR trial is a single-blind, single-centre, independent, and pragmatic randomised clinical trial comparing ministernotomy ("J" shaped upper hemisternotomy toward right 4th intercostal space) to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients will be randomised in a 1:1 computational fashion. Sample size was determined for the primary end point with alpha error of 0.05 and with power of 90% in detecting differences between intervention groups of ≥ 0.10 points in change from baseline quality of life Questionnaire EuroQOL-index (EQ-5D-5 L®), measured at 1, 6 or 12 months. Secondary endpoints are: the differences in change from other baseline EQ-5D-5 L® utilities (visual analogue scale, Health Index and Severity Index), cardiac surgery specific satisfaction questionnaire (SATISCORE®), a combined safety endpoint of four major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events and acute renal failure), bleeding through drains within the first 24 h, intubation time, postoperative hospital and intensive care unit length of stay, transfusion needs during the first 72 h and 1-year survival rates. Clinical follow up is scheduled at baseline, 1, 6, and 12 months after randomization. All clinical outcomes are recorded following the Valve Academic Research Consortium 2 criteria. DISCUSSION The QUALITY-AVR trial aims to test the hypothesis that ministernotomy improves quality of life, satisfaction and clinical outcomes in patients referred for isolated aortic valve replacement. Statistically significant differences favouring ministernotomy could modify the surgical "gold standard" for aortic stenosis surgery, and subsequently the need to change the control group in transcatheter aortic valve implantation trials. Recruitment started on 18 March 2016. In November 2017, 75 patients were enrolled. TRIAL REGISTRATION ClinicalTrials.gov , NCT02726087 . Registered on 13 March 2016.
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Affiliation(s)
- Emiliano A. Rodríguez-Caulo
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Guijarro-Contreras
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Otero-Forero
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - María José Mataró
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Sánchez-Espín
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Arantza Guzón
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Porras
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Miguel Such
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Ordóñez
- UGC Área del Corazón, Servicio de Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío de Sevilla, Red de Investigación Cardiovascular (RIC), Instituto de Salud Carlos III, Madrid, Spain
| | - José María Melero-Tejedor
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Jiménez-Navarro
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
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Schlömicher M, Taghiyev Z, AlJabery Y, Haldenwang PL, Zumholz M, Sikole M, Useini D, Naraghi H, Moustafine V, Bechtel M, Strauch JT. Rapid deployment aortic valve replacement in a minimal access setting: intermediate clinical and echocardiographic outcomes†. Eur J Cardiothorac Surg 2018; 54:354-360. [DOI: 10.1093/ejcts/ezy023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/07/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Markus Schlömicher
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Zulfugar Taghiyev
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Yazan AlJabery
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Peter Lukas Haldenwang
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Michael Zumholz
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Magdalena Sikole
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Dritan Useini
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Hamid Naraghi
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Vadim Moustafine
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Matthias Bechtel
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Justus Thomas Strauch
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
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Nguyen A, Stevens LM, Bouchard D, Demers P, Perrault LP, Carrier M. Early Outcomes with Rapid-deployment vs Stented Biological Valves: A Propensity-match Analysis. Semin Thorac Cardiovasc Surg 2018; 30:16-23. [DOI: 10.1053/j.semtcvs.2017.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 11/11/2022]
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Risteski P, El-Sayed Ahmad A, Monsefi N, Papadopoulos N, Radacki I, Herrmann E, Moritz A, Zierer A. Minimally invasive aortic arch surgery: Early and late outcomes. Int J Surg 2017; 45:113-117. [DOI: 10.1016/j.ijsu.2017.07.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/02/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023]
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Weymann A, Konertz J, Laule M, Stangl K, Dohmen PM. Are Sutureless Aortic Valves Suitable for Severe High-Risk Patients Suffering from Active Infective Aortic Valve Endocarditis? Med Sci Monit 2017; 23:2782-2787. [PMID: 28592789 PMCID: PMC5472401 DOI: 10.12659/msm.902785] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Sutureless aortic valves were introduced to facilitate minimally invasive aortic valve surgery. Since sutureless aortic valves are a feasible procedure, we evaluated if any benefits could be identified in severe high-risk patients with active infective endocarditis of the aortic valve. Material/Methods Between April 2014 and April 2015, a total of 42 patients received a sutureless Perceval® aortic valve (Sorin Biomedica Cardio Srl, Saluggia, Italy) for different indications. Nine of these patients (median age 71 years, range 47–83 years) suffered from active infective endocarditis, including four patients with prosthetic aortic valve endocarditis. Five patients underwent prior cardiac surgery, including transcatheter aortic valve implantation (TAVI). The median EuroSCORE II was 29.5% (range 16.8–87.7%). Post-operatively, data regarding mortality, operative results, and early operative morbidity were collected. Results There were no cases of 30-day mortality. Four patients needed abscess closure with pericardium. Three patients underwent left atrial appendix closure: one left ventricular thrombectomy, one bypass grafting, and one arch replacement. Median aortic cross-clamp and cardiopulmonary bypass time was 35 minutes (range 26–88 minutes) and 52 minutes (range 40–133 minutes), respectively. The median intubation time was 14 hours (range 1–9 hours). In these high-risk patients, no postoperative morbidity was found except for one re-intubation due to extensive delirium and one re-exploration. No pacemaker implantation was needed. Echocardiographic evaluation showed no central or para-valvular regurgitation, and a median discharge mean gradient of 5.5 mm Hg (range 2.5–10.0 mm Hg). Conclusions Sutureless aortic valve replacement in very high-risk patients suffering from active infection endocarditis seems to be an option with limited morbidity and appropriate echocardiographic results, however, further studies are needed.
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Affiliation(s)
- Alexander Weymann
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Johanna Konertz
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Michael Laule
- Department of Cardiology and Angiology, Charite Hospital, Medical University Berlin, Berlin, Germany
| | - Karl Stangl
- Department of Cardiology and Angiology, Charite Hospital, Medical University Berlin, Berlin, Germany
| | - Pascal M Dohmen
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.,Department of Cardiothoracic Surgery, Faculty of Health Science, Free State University, Bloemfontein, South Africa
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Moore M, Barnhart GR, Chitwood WR, Rizzo JA, Gunnarsson C, Palli SR, Grossi EA. The economic value of rapid deployment aortic valve replacement via full sternotomy. J Comp Eff Res 2017; 6:293-302. [DOI: 10.2217/cer-2016-0064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare the economic value of EDWARDS INTUITY Elite™ (EIE) valve system for rapid-deployment aortic valve replacement (RDAVR) in a full sternotomy (FS) approach (EIE-FS-RDAVR) versus FS-AVR using conventional stented bioprosthesis. Data & methods: A simulation model to compare each treatment's 30-day inpatient utilization and complication rates utilized: clinical end points obtained from the TRANSFORM trial patient subset (EIE-FS-RDAVR) and a best evidence review of the published literature (FS-AVR); and costs from the Premier database and published literature. Results: EIE-FS-RDAVR costs $800 less than FS-AVR per surgery episode attributable to lowered complication rates and utilization. Combined with the lower mortality, EIE-FS-RDAVR was a superior (dominant) technology versus FS-AVR. Conclusion: This preliminary investigation of EIE-FS-RDAVR versus conventional FS-AVR found the EIE valve offered superior economic value over a 30-day period. Real-world analyses with additional long-term follow-up are needed to evaluate if this result can be replicated over a longer timeframe.
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Affiliation(s)
- Matt Moore
- Edwards Lifesciences, Inc., Irvine, CA, USA
| | | | | | | | | | - Swetha R Palli
- CTI Clinical Trial & Consulting Services, Inc., Cincinnati, OH, USA
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Fudulu D, Lewis H, Benedetto U, Caputo M, Angelini G, Vohra HA. Minimally invasive aortic valve replacement in high risk patient groups. J Thorac Dis 2017; 9:1672-1696. [PMID: 28740685 DOI: 10.21037/jtd.2017.05.21] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts.
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Affiliation(s)
- Daniel Fudulu
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Harriet Lewis
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Umberto Benedetto
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Massimo Caputo
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Gianni Angelini
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Hunaid A Vohra
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
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Kirmani BH, Jones SG, Malaisrie SC, Chung DA, Williams RJNN. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev 2017; 4:CD011793. [PMID: 28394022 PMCID: PMC6478148 DOI: 10.1002/14651858.cd011793.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the centre ("median sternotomy") and replacing the valve under cardiopulmonary bypass. Median sternotomy is generally well tolerated, but as less invasive options have become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access has raised safety concerns with regards to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity. OBJECTIVES To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement. SEARCH METHODS We performed searches of CENTRAL, MEDLINE, Embase, clinical trials registries, and manufacturers' websites from inception to July 2016, with no language limitations. We reviewed references of identified papers to identify any further studies of relevance. SELECTION CRITERIA Randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, trans-apical, trans-femoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. The quality of evidence was determined using the GRADE methodology and results of patient-relevant outcomes were summarised in a 'Summary of findings' table. MAIN RESULTS The review included seven trials with 511 participants. These included adults from centres in Austria, Spain, Italy, Germany, France, and Egypt. We performed 12 comparisons investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy.There was no evidence of any effect of upper hemi-sternotomy on mortality versus full median sternotomy (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.36 to 2.82; participants = 511; studies = 7; moderate quality). There was no evidence of an increase in cardiopulmonary bypass time with aortic valve replacement performed via an upper hemi-sternotomy (mean difference (MD) 3.02 minutes, 95% CI -4.10 to 10.14; participants = 311; studies = 5; low quality). There was no evidence of an increase in aortic cross-clamp time (MD 0.95 minutes, 95% CI -3.45 to 5.35; participants = 391; studies = 6; low quality). None of the included studies reported major adverse cardiac and cerebrovascular events as a composite end point.There was no evidence of an effect on length of hospital stay through limited hemi-sternotomy (MD -1.31 days, 95% CI -2.63 to 0.01; participants = 297; studies = 5; I2 = 89%; very low quality). Postoperative blood loss was lower in the upper hemi-sternotomy group (MD -158.00 mL, 95% CI -303.24 to -12.76; participants = 297; studies = 5; moderate quality). The evidence did not support a reduction in deep sternal wound infections (RR 0.71, 95% CI 0.22 to 2.30; participants = 511; studies = 7; moderate quality) or re-exploration (RR 1.01, 95% CI 0.48 to 2.13; participants = 511; studies = 7; moderate quality). There was no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.33, 95% CI -0.85 to 0.20; participants = 197; studies = 3; I2 = 70%; very low quality), but there was a small increase in postoperative pulmonary function tests with minimally invasive limited sternotomy (MD 1.98 % predicted FEV1, 95% CI 0.62 to 3.33; participants = 257; studies = 4; I2 = 28%; low quality). There was a small reduction in length of intensive care unit stays as a result of the minimally invasive upper hemi-sternotomy (MD -0.57 days, 95% CI -0.93 to -0.20; participants = 297; studies = 5; low quality). Postoperative atrial fibrillation was not reduced with minimally invasive aortic valve replacement through limited compared to full sternotomy (RR 0.60, 95% CI 0.07 to 4.89; participants = 240; studies = 3; moderate quality), neither were postoperative ventilation times (MD -1.12 hours, 95% CI -3.43 to 1.19; participants = 297; studies = 5; low quality). None of the included studies reported cost analyses. AUTHORS' CONCLUSIONS The evidence in this review was assessed as generally low to moderate quality. The study sample sizes were small and underpowered to demonstrate differences in outcomes with low event rates. Clinical heterogeneity both between and within studies is a relatively fixed feature of surgical trials, and this also contributed to the need for caution in interpreting results.Considering these limitations, there was uncertainty of the effect on mortality or extracorporeal support times with upper hemi-sternotomy for aortic valve replacement compared to full median sternotomy. The evidence to support a reduction in total hospital length of stay or intensive care stay was low in quality. There was also uncertainty of any difference in the rates of other, secondary outcome measures or adverse events with minimally invasive limited sternotomy approaches to aortic valve replacement.There appears to be uncertainty between minimally invasive aortic valve replacement via upper hemi-sternotomy and conventional aortic valve replacement via a full median sternotomy. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality-of-life analyses to be included as end points, as well as quantitative measures of physiological reserve.
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Affiliation(s)
- Bilal H Kirmani
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
| | - Sion G Jones
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
| | - S C Malaisrie
- Northwestern UniversityDivision of Cardiac Surgery201 E. Huron StreetGalter 11‐140Chicago, ILUSA60611
| | - Darryl A Chung
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
| | - Richard JNN Williams
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
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Karangelis D, Mazine A, Roubelakis A, Alexiou C, Fragoulis S, Mazer CD, Yanagawa B, Latter D, Bonneau D. What is the role of sutureless aortic valves in today’s armamentarium? Expert Rev Cardiovasc Ther 2016; 15:83-91. [DOI: 10.1080/14779072.2017.1273108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Dimos Karangelis
- Department of Surgery, Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Amine Mazine
- Department of Surgery, Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Apostolos Roubelakis
- Department of Surgery, Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Christos Alexiou
- Department of Cardiac Surgery, Interbalkan European Medical Center, Thessaloniki, Greece
| | | | - C. David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Bobby Yanagawa
- Department of Surgery, Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - David Latter
- Department of Surgery, Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Daniel Bonneau
- Department of Surgery, Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada
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De Smet JM, Rondelet B, Jansens JL, Antoine M, De Cannière D, Le Clerc JL. Assessment Based on EuroSCORE of Ministernotomy for Aortic Valve Replacement. Asian Cardiovasc Thorac Ann 2016; 12:53-7. [PMID: 14977743 DOI: 10.1177/021849230401200113] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To assess the advantages of a ministernotomy over a standard sternotomy for aortic valve replacement, 191 patients were classified as low-, medium-, and high-risk by EuroSCORE. A ministernotomy was carried out in 100 patients, and a standard sternotomy was used in 91. Among low-risk patients, those who had a ministernotomy showed a marginal increase in atrial fibrillation. Of the medium-risk patients, those who had a sternotomy had significantly more atrial fibrillation and slightly more general infections. In the high-risk subgroup, significantly more atrial fibrillation was observed in the sternotomy group, and more neurologic events were observed in the ministernotomy group; the difference became nonsignificant when only severe events were considered. There was a significant benefit in terms of rhythm disturbances in medium- and high-risk patients who underwent a ministernotomy compared to those who had a full sternotomy. Mortality, duration of intensive care, and hospital stay were not influenced by the operative method.
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Affiliation(s)
- Jean-Marie De Smet
- Cardiac Surgery Service, Erasme Hospital, University of Brussels, Brussels, Belgium.
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Tabata M, Aranki SF, Fox JA, Couper GS, Cohn LH, Shekar PS. Minimally Invasive Aortic Valve Replacement in Left Ventricular Dysfunction. Asian Cardiovasc Thorac Ann 2016; 15:225-8. [PMID: 17540992 DOI: 10.1177/021849230701500310] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The safety and benefit of minimally invasive aortic valve replacement in patients with left ventricular dysfunction has not been well investigated. We conducted a retrospective review of 140 patients with ejection fraction ≤ 40% who underwent isolated aortic valve replacement between July 1996 and March 2005. Aortic valve replacement was performed via an upper hemisternotomy in 73 patients and via a full sternotomy in 67. Two matched cohorts of 41 patients each were constructed using propensity score analysis, and the outcomes were compared. There was no significant difference in operative mortality (hemisternotomy, 2.4% vs 4.8% for full sternotomy), incidence of postoperative complications, blood transfusion requirement, length of hospital stay, or discharge to home rates. Aortic valve replacement via an upper hemisternotomy can be performed safely, even in patients with left ventricular dysfunction, with morbidity and mortality outcomes similar to those of a full sternotomy.
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Affiliation(s)
- Minoru Tabata
- Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Acharya M, Harling L, Moscarelli M, Ashrafian H, Athanasiou T, Casula R. Influence of body mass index on outcomes after minimal-access aortic valve replacement through a J-shaped partial upper sternotomy. J Cardiothorac Surg 2016; 11:74. [PMID: 27118140 PMCID: PMC4847251 DOI: 10.1186/s13019-016-0467-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/17/2016] [Indexed: 12/03/2022] Open
Abstract
Background Minimal-access aortic valve replacement (MAAVR) may reduce post-operative blood loss and transfusion requirements, decrease post-operative pain, shorten length stay and enhance cosmesis. This may be particularly advantageous in overweight/obese patients, who are at increased risk of post-operative complications. Obese patients are however often denied MAAVR due to the perceived technical procedural difficulty. This retrospective analysis sought to determine the effect of BMI on post-operative outcomes in patients undergoing MAAVR. Methods Ninety isolated elective MAAVR procedures performed between May 2006–October 2013 were included. Intra- and post-operative data were prospectively collected. Ordinary least squares univariate linear regression analysis was performed to determine the effect of BMI as a continuous variable on post-operative outcomes. One-way ANOVA and Chi-squared testing was used to assess differences in outcomes between patients with BMI <25 (n = 36) and BMI ≥25 (n = 54) as appropriate. Results There was no peri-operative mortality, myocardial infarction or stroke. Univariate regression demonstrated longer cross-clamp times (p = 0.0218) and a trend towards increased bypass times (p = 0.0615) in patients with higher BMI. BMI ≥25 was associated with an increased incidence of hospital-acquired pneumonia (p = 0.020) and new-onset atrial fibrillation (p = 0.036) compared to BMI <25. However, raised BMI did not extend ICU (p = 0.3310) or overall hospital stay (p = 0.2614). Similar rates of sternal wound complications, inotrope requirements and renal dysfunction were observed in both normal- and overweight/obese-BMI groups. Furthermore, increasing BMI correlated with reduced mechanical ventilation time (p = 0.039) and early post-operative blood loss (p = 0.004). Conclusions Our results demonstrate that within the range of this study, MAAVR is a safe, reproducible and effective procedure, affording equivalent clinical outcomes in both overweight/obese and normal-weight patients considered for an isolated first-time AVR, with low post-operative morbidity and mortality. MAAVR should therefore be considered as an alternative surgical strategy to reduce obesity-related complications in patients requiring aortic valve replacement.
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Affiliation(s)
- Metesh Acharya
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Leanne Harling
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK. .,The Department of Surgery and Cancer, 10th Floor QEQM Building, St Mary's Hospital, Praed St., London, W2 1NY, UK.
| | - Marco Moscarelli
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Hutan Ashrafian
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Roberto Casula
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
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Borger MA, Dohmen PM, Knosalla C, Hammerschmidt R, Merk DR, Richter M, Doenst T, Conradi L, Treede H, Moustafine V, Holzhey DM, Duhay F, Strauch J. Haemodynamic benefits of rapid deployment aortic valve replacement via a minimally invasive approach: 1-year results of a prospective multicentre randomized controlled trial. Eur J Cardiothorac Surg 2016; 50:713-720. [DOI: 10.1093/ejcts/ezw042] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/26/2016] [Accepted: 02/03/2016] [Indexed: 01/22/2023] Open
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Wahlers TCW, Haverich A, Borger MA, Shrestha M, Kocher AA, Walther T, Roth M, Misfeld M, Mohr FW, Kempfert J, Dohmen PM, Schmitz C, Rahmanian P, Wiedemann D, Duhay FG, Laufer G. Early outcomes after isolated aortic valve replacement with rapid deployment aortic valve. J Thorac Cardiovasc Surg 2016; 151:1639-47. [PMID: 26892076 DOI: 10.1016/j.jtcvs.2015.12.058] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 12/01/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Minimal access aortic valve replacement is associated with favorable clinical outcomes; however, several meta-analyses have reported significantly longer crossclamp times compared with a full sternotomy. We examined the procedural and early safety outcomes after isolated rapid deployment aortic valve replacement by surgical approach in patients enrolled in the Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve trial. METHODS The Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve trial was a prospective, multicenter, single-arm study, with successful implants in 287 patients with aortic valve stenosis who underwent rapid deployment aortic valve replacement using the EDWARDS INTUITY Valve System (Edwards Lifesciences, Irvine, Calif). Patients were evaluated perioperatively for procedural times and technical success rates; at discharge, for hospital length of stay; and, at 30 days, for early adverse events. RESULTS A total of 158 patients underwent isolated aortic valve replacement through a full sternotomy (n = 71), upper hemisternotomy (n = 77), or right anterior thoracotomy (n = 10). Mean age at baseline was 75.7 ± 7.2 years. Mean aortic crossclamp and cardiopulmonary bypass times (minutes) were similar for full sternotomy and upper hemisternotomy, 43.5 ± 32.5/71.6 ± 41.8 and 43.1 ± 13.1/69.6 ± 19.1, respectively, and significantly longer for right anterior thoracotomy, 88.3 ± 18.6/122.2 ± 22.1 (P < .000). Early adverse event rates were similar, and in-hospital mortality rates were low regardless of surgical approach. CONCLUSIONS These data suggest that isolated rapid deployment aortic valve replacement through an upper hemisternotomy can lead to shorter crossclamp times than has been reported historically in the literature. This may facilitate minimal access aortic valve replacement by eliminating the issue of prolonged crossclamp times. Further, low in-hospital mortality and new permanent pacemaker implant rates were observed regardless of surgical approach.
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Mini-aortic valve replacements are not associated with an increased incidence of patient–prosthesis mismatch: a propensity-scored analysis. Gen Thorac Cardiovasc Surg 2015; 64:144-8. [DOI: 10.1007/s11748-015-0614-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/04/2015] [Indexed: 11/26/2022]
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Abstract
With the advent of transcatheter aortic valve replacement and the emergence of rapid deployment aortic valves, there is a resurgent interest in minimizing the trauma of surgical aortic valve replacement (AVR). The present review summarizes the history of minimal access AVR and attempts to collate the existing evidence regarding minimal access AVR.
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Affiliation(s)
- Rawn Salenger
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Julia A Collins
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
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Concurrent Minimally Invasive Aortic Valve Replacement and Coronary Artery Bypass via Limited Right Anterior Thoracotomy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:273-5. [PMID: 26355689 DOI: 10.1097/imi.0000000000000170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An 89-year-old man and an 80-year-old woman were treated surgically for critical aortic stenosis secondary to senile calcific aortic disease and high-grade calcified lesions in the ostium of the right coronary artery. Minimally invasive aortic valve replacement and concurrent coronary artery bypass grafting were performed concurrently through a 5-cm right anterior thoracotomy in the second intercostal space. Surgery was uncomplicated in both cases, with no adverse events. Both patients were alive and well at midterm follow-up. Concurrent minimally invasive aortic valve replacement and coronary artery bypass grafting can be performed successfully through a limited right anterior thoracotomy.
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Abordaje mínimamente invasivo para el recambio valvular aórtico: ¿está asociado a menor transfusión de hemoderivados? CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Corona Perezgrovas MÁ, Sagahón Martínez JA, Hernández Mejía BI, Martínez Hernández HJ, Herrera Alarcón V. Abordaje mínimamente invasivo versus esternotomía total en la sustitución valvular aórtica: estudio comparativo de la evolución posoperatoria temprana. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Concurrent Minimally Invasive Aortic Valve Replacement and Coronary Artery Bypass via Limited Right Anterior Thoracotomy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000409] [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]
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Kaczmarczyk M, Szałański P, Zembala M, Filipiak K, Karolak W, Wojarski J, Garbacz M, Kaczmarczyk A, Kwiecień A, Zembala M. Minimally invasive aortic valve replacement - pros and cons of keyhole aortic surgery. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2015; 12:103-10. [PMID: 26336491 PMCID: PMC4550017 DOI: 10.5114/kitp.2015.52850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 04/13/2015] [Accepted: 05/22/2015] [Indexed: 11/26/2022]
Abstract
Over the last twenty years, minimally invasive aortic valve replacement (MIAVR) has evolved into a safe, well-tolerated and efficient surgical treatment option for aortic valve disease. It has been shown to reduce postoperative morbidity, providing faster recovery and rehabilitation, shorter hospital stay and better cosmetic results compared with conventional surgery. A variety of minimally invasive accesses have been developed and utilized to date. This concise review demonstrates and discusses surgical techniques used in contemporary approaches to MIAVR and presents the most important results of MIAVR procedures.
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Affiliation(s)
- Marcin Kaczmarczyk
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Michał Zembala
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Krzysztof Filipiak
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Wojciech Karolak
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Jacek Wojarski
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Marcin Garbacz
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Aleksandra Kaczmarczyk
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Anna Kwiecień
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Marian Zembala
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
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Borger MA. Minimally invasive rapid deployment Edwards Intuity aortic valve implantation. Ann Cardiothorac Surg 2015; 4:193-5. [PMID: 25870818 DOI: 10.3978/j.issn.2225-319x.2014.11.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/25/2014] [Indexed: 11/14/2022]
Affiliation(s)
- Michael A Borger
- Division of Cardiac, Vascular and Thoracic Surgery, Columbia University Medical Center, New York, USA
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Gilmanov D, Solinas M, Farneti PA, Cerillo AG, Kallushi E, Santarelli F, Glauber M. Minimally invasive aortic valve replacement: 12-year single center experience. Ann Cardiothorac Surg 2015; 4:160-9. [PMID: 25870812 DOI: 10.3978/j.issn.2225-319x.2014.12.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/08/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND This study reports the single center experience on minimally invasive aortic valve replacement (MIAVR), performed through a right anterior minithoracotomy or ministernotomy (MS). METHODS Eight hundred and fifty-three patients, who underwent MIAVR from 2002 to 2014, were retrospectively analyzed. Survival was evaluated using the Kaplan-Meier method. The Cox multivariable proportional hazards regression model was developed to identify independent predictors of follow-up mortality. RESULTS Median age was 73.8, and 405 (47.5%) of patients were female. The overall 30-day mortality was 1.9%. Four hundred and forty-three (51.9%) and 368 (43.1%) patients received biological and sutureless prostheses, respectively. Median cardiopulmonary bypass time and aortic cross-clamping time were 108 and 75 minutes, respectively. Nineteen (2.2%) cases required conversion to full median sternotomy. Thirty-seven (4.3%) patients required re-exploration for bleeding. Perioperative stroke occurred in 15 (1.8%) patients, while transient ischemic attack occurred postoperative in 11 (1.3%). New onset atrial fibrillation was reported for 243 (28.5%) patients. After a median follow-up of 29.1 months (2,676.0 patient-years), survival rates at 1 and 5 years were 96%±1% and 80%±3%, respectively. Cox multivariable analysis showed that advanced age, history of cardiac arrhythmia, preoperative chronic renal failure, MS approach, prolonged mechanical ventilation and hospital stay as well as wound revision were associated with higher mortality. CONCLUSIONS MIAVR via both approaches is safe and feasible with excellent outcomes, and is associated with low conversion rate and low perioperative morbidity. Long term survival is at least comparable to that reported for conventional sternotomy AVR.
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Affiliation(s)
- Daniyar Gilmanov
- Department of Adult Cardiac Surgery, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart hospital, Massa, MS 54100, Italy
| | - Marco Solinas
- Department of Adult Cardiac Surgery, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart hospital, Massa, MS 54100, Italy
| | - Pier Andrea Farneti
- Department of Adult Cardiac Surgery, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart hospital, Massa, MS 54100, Italy
| | - Alfredo Giuseppe Cerillo
- Department of Adult Cardiac Surgery, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart hospital, Massa, MS 54100, Italy
| | - Enkel Kallushi
- Department of Adult Cardiac Surgery, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart hospital, Massa, MS 54100, Italy
| | - Filippo Santarelli
- Department of Adult Cardiac Surgery, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart hospital, Massa, MS 54100, Italy
| | - Mattia Glauber
- Department of Adult Cardiac Surgery, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart hospital, Massa, MS 54100, Italy
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Sutureless prostheses and less invasive aortic valve replacement: just an issue of clamping time? Ann Thorac Surg 2015; 99:1518-23. [PMID: 25757759 DOI: 10.1016/j.athoracsur.2014.12.072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 12/17/2014] [Accepted: 12/30/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recently, sutureless aortic bioprostheses have been increasingly adopted to facilitate minimally invasive aortic valve replacement. We aimed at evaluating the impact of the transition from conventional bioprostheses to the routine use of the 3f Enable prosthesis (Medtronic ATS Medical, Minneapolis, MN) for aortic valve replacement through ministernotomy. METHODS Between November 2009 and November 2012, 83 consecutive minimally invasive aortic valve replacement procedures were performed in our institution by the same surgeon through an upper T-shaped ministernotomy. The earliest 42 patients (group A) received a conventional bioprosthesis, and the later 41 patients (group B) received the sutureless 3f Enable valve. Aortic clamping and cardiopulmonary bypass times, early outcomes, and valve hemodynamics were compared. RESULTS There was no statistical intergroup difference in baseline characteristics. In-hospital mortality was 1% (a single nonvalve-related death). Average aortic clamping times in group A and group B were, respectively, 85 ± 17 and 47 ± 11 minutes (p < 0.0001); the cardiopulmonary bypass time was 108 ± 21 and 69 ± 15 minutes, respectively (p < 0.0001). There were three paravalvular leakages in group A (grade I) and four in group B (two grade I, and two grade II); three pacemaker implantations occurred in group B (p = 0.07); mean transvalvular gradient at discharge was 16.9 ± 9.1 mm Hg in group A and 11.4 ± 4.3 mm Hg in group B (p = 0.0007). During follow-up (average 25.5 ± 12.9 months), one structural valve deterioration was registered in group A, and was treated with a valve-in-valve procedure. CONCLUSIONS In our initial experience, the sutureless 3f Enable technology significantly reduced the clamping and cardiopulmonary bypass times, as well as the mean transvalvular gradient in aortic valve replacement through ministernotomy.
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An innovative minimally invasive technique for aortic valve replacement. Eur Heart J Suppl 2015. [DOI: 10.1093/eurheartj/suv007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Neely RC, Boskovski MT, Gosev I, Kaneko T, McGurk S, Leacche M, Cohn LH. Minimally invasive aortic valve replacement versus aortic valve replacement through full sternotomy: the Brigham and Women's Hospital experience. Ann Cardiothorac Surg 2015; 4:38-48. [PMID: 25694975 DOI: 10.3978/j.issn.2225-319x.2014.08.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 08/13/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Minimally invasive aortic valve surgery (mini AVR) is a safe and effective treatment option at many hospital centers, but there has not been widespread adoption of the procedure. Critics of mini AVR have called for additional evidence with direct comparison to aortic valve replacement (AVR) via full sternotomy (FS). METHODS Our mini AVR approach is through a hemi-sternotomy (HS). We performed a propensity-score matched analysis of all patients undergoing isolated AVR via FS or HS at our institution since 2002, resulting in 552 matched pairs. Baseline characteristics were similar. Operative characteristics, transfusion rates, in-hospital outcomes as well as short and long term survival were compared between groups. RESULTS Median cardiopulmonary bypass and cross clamp times were shorter in the HS group: 106 minutes [inter-quartile ranges (IQR) 87-135] vs. 124 minutes (IQR 90-169), P≤0.001, and 76 minutes (IQR 63-97) vs. 80 minutes (IQR 62-114), P≤0.005, respectively. HS patients had shorter ventilation times (median 5.7 hours, IQR 3.5-10.3 vs. 6.3 hours, IQR 3.9-11.2, P≤0.022), shorter intensive care unit stay (median 42 hours, IQR 24-71 vs. 45 hours, IQR 24-87, P≤0.039), and shorter hospital length of stay (median 6 days, IQR 5-8 vs. 7 days, IQR 5-10, P≤0.001) compared with the FS group. Intraoperative transfusions were more common in FS group: 27.9% vs. 20.0%, P≤0.003. No differences were seen in short or long term survival, or time to aortic valve re-intervention. CONCLUSIONS Our study confirms the clinical benefits of minimally invasive AVR via HS, which includes decreased transfusion requirements, ventilation times, intensive care unit and hospital length of stay without compromising short and long term survival compared to conventional AVR via FS.
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Affiliation(s)
- Robert C Neely
- Division of Cardiac Surgery, The Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marko T Boskovski
- Division of Cardiac Surgery, The Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Igor Gosev
- Division of Cardiac Surgery, The Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, The Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Siobhan McGurk
- Division of Cardiac Surgery, The Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marzia Leacche
- Division of Cardiac Surgery, The Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence H Cohn
- Division of Cardiac Surgery, The Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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