Minimally invasive aortic valve replacement: echocardiographic and clinical results

Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement

BACKGROUND

Propensity score-matched analysis of the anterolateral minithoracotomy and the partial upper hemisternotomy vs the median sternotomy approach has not been reported to date for isolated aortic valve replacement.

METHODS

From 2005 to 2013, isolated aortic valve replacement was performed through a partial upper hemisternotomy in 315 patients (38.9%), through a median sternotomy in 328 patients (40.5%), and through an anterolateral minithoracotomy in 167 patients (20.6%). After propensity score-matched analysis, both minimally invasive techniques were independently compared with median sternotomy in 118 matched pairs.

RESULTS

In the anterolateral group, conversion to median sternotomy was significantly higher (17 [14.4%]), a second pump run (6 [5.1%]) and second cross clamp (12 [10.2%]) were significantly more often necessary, the median cross-clamp time (94 minutes; range, 43 to 231 minutes) and median perfusion time (141 minutes; range, 77 to 456 minutes) were significantly longer, and more groin complications occurred (17 [14.4%]), all compared with the median sternotomy group. No difference in perioperative results was identified between the partial upper hemisternotomy and the median sternotomy group. There was no significant difference in 1-year survival among the three groups, although a trend of better survival was observed in the partial upper hemisternotomy group.

CONCLUSIONS

In minimally invasive isolated aortic valve replacement, the partial upper hemisternotomy shows similar perioperative outcome as the median sternotomy, whereas, the anterolateral minithoracotomy is associated with more perioperative complications. Therefore, only the partial upper hemisternotomy should be the preferred surgical technique for minimally invasive aortic valve replacement in the daily routine for a broad spectrum of surgeons.

Intraoperative Echocardiography: Support for Decision Making in Cardiac Surgery

Intraoperative echocardiography (including transesophageal echocardiography, epiaortic ultrasound and epicardial echocardiography) is commonly performed in North American hospitals during cardiac anesthesia. Several authors have reported on the positive impact of intraoperative echocardiography on patients’ outcomes. Transesophageal echocardiography is useful in identifying anatomic and functional abnormalities either before or after cardiopulmonary bypass and helps to make decisions in the care of high-risk and unstable patients. In minimally invasive and robotically assisted surgery, transesophageal echocardiography is essential in order to guide cannulation of venous and arterial vessels for cardiopulmonary bypass and in providing immediate assessment of the quality of the performed repair. Intraoperative echocardiography can also detect complications associated with the performed procedure and can be an excellent hemodynamic monitor in unstable patients. In this paper different scenarios where intraoperative echocardiography is useful are reviewed, some clinical cases are shown to illustrate, and a review of related literature is reported.

Pulmonary Complications After Cardiac Surgery

Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of “off-pump” surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.

Aortic valve replacement via right minithoracotomy versus median sternotomy: a propensity score analysis

OBJECTIVE

The aim of this study was to define the relative role of a right minithoracotomy (RT) versus standard median sternotomy (ST) for open aortic valve replacement (AVR).

METHODS

A retrospective analysis was performed of all 1348 patients undergoing isolated, open AVR at a single institution during a 14-year period. Because relatively few patients were technically suitable for redo AVR with the RT approach (n = 20), all redo patients (n = 209) were excluded, leaving 1139 patients available for analysis. Patients converting from RT to ST approach (n = 15) were analyzed separately.

RESULTS

Relative to ST (n = 672), the RT patients (n = 452) were older with more stenosis but with more recent operation year, lower rate of congestive heart failure, higher ejection fraction, lower rate of endocarditis, and lower rate of renal disease than the ST AVR patients (all P < 0.0001). Right minithoracotomy AVR was associated with longer cardiopulmonary bypass times [157 (25) vs 131 (38), P = 0.0004] and clamp times [103 (20) vs 85 (27), P < 0.0001] but less transfusion (1.4 vs 3.4 U, P = 0.0003), less chest tube output (405 vs 950 mL, P < 0.0001), fewer reoperations for bleeding (0.4% vs 4%, P < 0.0001), shorter length of stay (6 vs 8 days, P = 0.03), and lower rate of atrial fibrillation (15% vs 20%, P = 0.03). Stroke, operative mortality, and survival were not significantly different between the groups.

CONCLUSIONS

Given the biases of retrospective propensity-adjusted analysis, these data suggest that RT AVR is a safe alternative to ST AVR in selected patients, with advantages of avoiding sternotomy with associated bleeding, transfusion, and delayed wound healing, at the expense of longer pump and clamp times.

Port-access double valve replacement: first case report in Japan

A 57-year-old man with mitral and aortic valve stenosis was admitted to our hospital. An electrocardiogram showed atrial fibrillation. After receiving informed consent, we performed a double valve replacement (DVR) with bioprostheses and maze procedure, utilizing a port-access technique. The operation and aortic cross-clamping times were 460 and 228 min, respectively. The patient's recovery was uneventful and he was discharged from our hospital with a consistent sinus rhythm 22 days after surgery. This is the first case report of port-access DVR in Japan.

Aortic Valve Replacement through Right Minithoracotomy in 306 Consecutive Patients

Objective

To define the role and early results of aortic valve surgery through a right minithoracotomy.

Methods

A retrospective analysis was performed on 306 consecutive patients undergoing aortic valve replacement through an 8-cm right minithoracotomy in the second intercostal space. The initial experience was included. The right second and third ribs were detached from the sternum in most cases and repaired at the end of each case. Most operations were performed using anterograde and retrograde cardioplegic arrest with percutaneous femoral venous cannulation and direct aortic cannulation through the incision. Standard instruments were used with direct digital knot tying.

Results

Mean age was 65 ± 14 (range, 20–90) years. Aortic valve disease cause was calcific disease in 160 of 306 (52%) patients, bicuspid disease in 95 of 306 (31%) patients, and endocarditis in 9 of 306 (3%) patients. Previous cardiac surgery was present in 13 of 306 (4%) patients. Biologic prostheses were used in 240 of 306 (78%) patients. Median valve size was 23 mm. Mean clamp times and pump times were 103 ± 26 and 158 ± 35 minutes, respectively. Median postoperative length of stay was 5 days. Thirty-day mortality was found in 4 of 306 (1%) cases. There were no deep wound infections or mediastinitis. Stroke occurred in 5 of 306 (1.6%) patients, and new pacemaker required in 11 of 306 (4%) patients. Reoperation for bleeding occurred in 2 of 306 (1%) patients. Conversion to median sternotomy occurred in 15 of 306 (5%) patients caused by chest wall anatomy (n = 7), bleeding (n = 3), coronary disease (n = 2), or aortic disease (n = 3). Patients were allowed to return to driving or preoperative activity in 2 weeks. With a mean follow-up of 2.8 ± 2.2 years, one patient required reoperation for aortic root disease.

Conclusions

Right minithoracotomy is a safe but limited alternative to sternotomy in isolated aortic valve replacement. This approach may be particularly valuable in some higher risk, elderly patients and opens options for a hybrid approach combined with percutaneous coronary angioplasty.

Aortic valve replacement surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups

BACKGROUND

In the past decade, minimally invasive approaches have been developed for aortic valve surgery. We reviewed our data to determine if the use of the PORT ACCESS technique has improved hospital morbidity and mortality.

METHODS

Data were collected on 90 patients who had a replacement of their aortic valve using PORT ACCESS procedures (PORT ACCESS aortic valve replacement [PAVR]). This group was then matched 1:4 to a control group having aortic valve replacement surgery using a standard sternotomy approach.

RESULTS

The two groups had no statistically significant differences in preoperative risk factors. The perioperative and 30-day outcomes from the matched AVR and PAVR groups showed no mortalities in the PAVR group and 3.1% in the AVR group. Mean length of stay was shorter for PAVR patients (7.2 +/- 5.0 days; median 6 days) compared with the mean stay in the sternotomy group (8.5 +/- 9.5 days; median 6 days), PAVR patients also had statistically significant shorter intensive care unit stays, and time on ventilator. The number of patients needing ventilator support postoperatively was significantly lower in the PORT ACCESS group. Cross-clamp and perfusion times were longer in the PAVR group. No other morbidity was significantly different between groups, except for postoperative tamponade (higher in PAVR group).

CONCLUSIONS

In this analysis of matched patients, the patients having aortic valve replacement using PORT ACCESS procedures, spent a shorter time in the intensive care unit and had less need for postoperative ventilator usage (both number of patients using a ventilator and the mean time of use) in comparison with patients undergoing conventional sternotomy.

Port-access aortic valve replacement

A 42-year-old man suffering from massive aortic valve regurgitation with mild stenosis because of a bicuspid valve underwent surgery in May 2007. The surgical procedure was performed through a right anterolateral thoracotomy using the peripheral cannulation method. Cardiac arrest was achieved by direct aortic cross-clamping and selective cardioplegia delivery. The aortic valve was replaced with a bioprosthesis. The operation and aortic cross-clamping periods were 265 and 117 min, respectively. The patient's recovery was uneventful, and he was discharged from hospital 8 days after surgery.

Port-access aortic valve surgery: a technique in evolution

BACKGROUND

Innovative minimally invasive surgical techniques have been developed for treating many cardiac diseases. We reviewed our experience with port-access aortic valve replacement (PAVR) surgery.

METHODS

We retrospectively reviewed the charts of patients with aortic valve disease who underwent surgical correction using the Heartport System and minithoracotomy (PAVR) from January 1998 to December 2002 (n = 58) and matched them 1:1 with a cohort of patients who underwent AVR with conventional sternotomy.

RESULTS

No preoperative statistical differences existed between the groups, including age, sex, New York Heart Association class, and ejection fraction. Perioperatively, there was a statistically significant difference between the AVR and PAVR groups with regard to aortic cross-clamp time (74.0 +/- 22.9 minutes versus 92.7 +/- 20.4 minutes, P < .01). Average operative times improved in the PAVR group by almost 83 minutes from the first 10 patients to patients 21 to 31 (P = .05). PAVR patients also averaged shorter stays in the intensive care unit (ICU) (1.5 days less) and hospital (1.8 days less) and were extubated sooner (4.9 hours). Mortality (1/58, 1.7%) and morbidity (reoperation for bleeding, infection, and stroke) were similar for both groups.

CONCLUSIONS

This minimally invasive approach to aortic valve surgery allows patients to be extubated earlier and promotes shorter stays in the ICU and hospital. These data suggest that the PA approach is an attractive alternative for patients requiring aortic valve surgery. There also appears to be a rapid surgeon learning curve.

Aortic valve replacement through a mini lateral thoracotomy with high thoracic epidural anesthesia

BACKGROUND

: Minimally invasive aortic valve surgery is usually performed through a right parasternal incision or a modification of partial sternotomy. We explored the feasibility of using a video-assisted small right lateral thoracotomy (RLT) to approach the aortic valve.

METHODS

: From August 2003 to December 2004, 12 patients with aortic stenosis (9) or regurgitation (3) underwent an aortic valve replacement through an 8 cm RLT in the 4th intercostal space. There were 4 men and 8 women with a mean age of 61 years (range 30-79 years). Nine mechanical and 3 biologic prostheses were implanted. Endotracheal narcosis was combined with high thoracic epidural anesthesia. Transesophageal echocardiographic monitoring was performed in all cases. Cannulation was done via the right femoral artery and vein and right jugular vein. The video-assisted operation was performed in moderate hypothermia (30°C) and in cardioplegic arrest. Transthoracic aortic clamping was used in all cases.

RESULTS

: Mean operation, perfusion, and clamping times were 223 minutes, 132 minutes, and 73 minutes, respectively. There was no mortality. One patient required conversion to sternotomy due to discovery of a calcium fragment entrapped in a mechanical prosthesis. One patient developed a groin seroma that was treated surgically. All patients, except one were extubated in the operative room and transferred to the intermediate care unit after 6 hours; all had an uneventful recovery.

CONCLUSIONS

: Aortic valve replacement through an RLT is feasible and safe. Operative time, perfusion, and cross-clamping times are only marginally longer than a conventional operation, and recovery is rapid.

Minimally Invasive Approaches to Aortic Valve Surgery: Brigham Experience

Aortic valve surgery is a proven and effective therapy for severe aortic stenosis and insufficiency. Conventional aortic valve surgery is performed with a full sternotomy, cardiopulmonary bypass, and replacement of the diseased aortic valve. Unlike minimally invasive (or "off-pump") coronary artery bypass, minimally invasive aortic valve surgery still requires cardiopulmonary bypass but refers primarily to smaller incisions and access. Minimally invasive approaches to aortic valve surgery have evolved over the past decade and have become the standard in institutions that perform large-volume minimally invasive cardiac surgery. The upper hemisternotomy has become our standard approach to isolated aortic valve surgery. It is a safe and effective technique with a similar morbidity and mortality to conventional aortic valve surgery. Patients derive clear benefits from this minimally invasive approach including less pain, shorter length of hospital stay, and faster return to preoperative function levels.

Minimally Invasive Reoperative Isolated Valve Surgery: Early and Mid-Term Results

OBJECTIVE

Minimally invasive, nonsternotomy approaches for valve procedures may reduce the risks associated with cardiac surgery after prior sternotomy and may improve outcomes. We analyzed our institutional experience to test this hypothesis.

METHODS

Between 1995 and 2002, 498 patients with previous cardiac operations via sternotomy underwent isolated valve surgery: 337 via median sternotomy (aortic = 160; mitral = 177) and 161 via mini-thoracotomy (aortic = 61; mitral = 100). Data were collected prospectively using the New York State Cardiac Surgery Report Form.

RESULTS

Preoperative incidences of congestive heart failure, renal disease, and nonelective procedures were higher in the sternotomy group. Hospital mortality was significantly lower with the minimally invasive approach, 5.6% (9/161) versus 11.3% (38/337) (univariate, p = 0.04). However, multivariate analysis (odds ratio: 95% confidence intervals, p value) revealed that chronic obstructive pulmonary disease (6.6: 1.4 to 3.1, p = 0.001), renal disease (4.1: 1.52 to 11.2, p = 0.01), cerebrovascular disease (2.2: 1.03 to 4.78, p = 0.04), and ejection faction <30% (1.5: 0.96 to 5.5, p = 0.06) were associated with increased mortality. While mean bypass time, cross-clamp times, and stroke rates were comparable between groups, patients undergoing minimally invasive valve surgery had no deep wound infections (0% vs 2.4%, p = 0.05), less need for blood products (p = 0.02), and shorter hospital stays (p = 0.009). Five-year survival was higher with minimally invasive techniques as compared to a sternotomy approach (92.4 +/- 2% and 86.0 +/- 2%, respectively, p = 0.08).

CONCLUSIONS

Reoperative valve surgery can be safely performed using a nonsternotomy, minimally invasive approach, with at least equal mortality, less hospital morbidity, decreased hospital length of stay, and slightly favorable mid-term survival as compared to sternotomy.

Port-Access-Assisted Aortic Valve Replacement: A Comparison of Minimally Invasive and Conventional Techniques

BACKGROUND

A hybrid Port-Access (PA) approach to aortic valve surgery (MPAVR) was designed as a less invasive aortic valve operation. The approach combines components of Port-Access technology with conventional cardiac surgical techniques via a limited sternal incision. This technique is compared to conventional aortic vale replacement (CAVR) for safety and efficacy.

METHODS

One hundred eighty patients had aortic valve surgery between January 1, 2000, and June 30, 2004. Fifty-eight patients (32%) had primary isolated aortic valve replacement, 22 of those 58 patients (38%) underwent MPAVR procedures consisting of a limited inverted-T sternotomy, direct aortic cannulation, a percutaneous PA endocoronary sinus cardioplegia catheter, an endovent pulmonary artery catheter, and a percutaneous femoral endovenous return catheter. Thirty-six patients (62%) had aortic valve replacement by sternotomy and standard cardiopulmonary bypass techniques. The MPAVR and CAVR groups were compared for demographics and intraoperative and postoperative outcomes.

RESULTS

Age, obesity, diabetes, New York Heart Association classification, ejection fraction, and other patient characteristics were not significantly different between the groups. MPAVR patients had lower Society of Thoracic Surgery risk scores (3.1 versus 3.9; P = .277). MPAVR patients were more likely to receive a stentless valve (36% versus 11%; P = .042) and required longer operative times (237 min versus 189 min; P <.001). Postoperative complications were minimal and equivalent. A single mortality in the CAVR group resulted in an overall mortality of 1.7%.

CONCLUSION

This hybrid, less invasive PA-assisted approach to aortic valve surgery is safe and effective. A total sternotomy can be avoided in selected aortic valve patients. Results equivalent to CAVR can be expected with this minimal access operation.

Percutaneous closure of prosthetic paravalvular leaks: Case series and review

BACKGROUND

Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valve replacement. Most are asymptomatic and benign, but some may cause symptoms due to a large regurgitant volume or hemolysis. Medical therapy is palliative, while reoperation carries significant morbidity and mortality. Percutaneous transcatheter closure techniques, now routinely applied in the management of pathological cardiac and vascular communications, may be adaptable to PVL closure, potentially offer symptomatic relief.

METHODS

We reviewed our experience with attempted percutaneous closure of PVLs, using data from medical and procedural records.

RESULTS

Between 2001 and 2004, 14 procedures were performed in 10 patients, all under general anesthesia, with transesophageal and radiographic guidance. Mitral (9) and aortic (1) valve replacements were involved, both mechanical and bioprosthetic. A variety of devices were used, including atrial septal occluders, patent ductus arteriosus occluders, and coils (all of label use). Six had a single procedure, which was technically successful in four: in two, the PVL could not be crossed. Four underwent a second procedure, which was technically successful in three; in one the previously deployed device was dislodged necessitating urgent, but ultimately uneventful, surgical removal and leak repair. One patient had transient severe hemolysis, which resolved after 1 week. At 1-year follow-up (9/10 pts) three had died, five had sustained symptomatic improvement while 1 patient with a residual leak still required regular blood transfusions.

CONCLUSIONS

Percutaneous closure of PVLs is time-consuming but feasible in selected patients, with a reasonable degree of technical and clinical success. A second procedure may be necessary and a variety of complications can occur.

Intraoperative Echocardiography in Minimally Invasive Cardiac Surgery and Novel Cardiovascular Surgical Techniques

Minimally invasive cardiovascular surgery has been developed in an effort to decrease hospital length of stay and cost by decreasing pulmonary and neurologic complications, pain, chest trauma, and infection. The smaller incisions provide less direct cardiac visualization and exposure, which makes transesophageal echocardiography an essential and integral part of these innovative procedures. Transesophageal echocardiography does not obstruct the surgical field and can perform a full evaluation of the heart. This includes assessment of the aorta and great vessels, valve function, ventricular wall motion, placement of catheters and cannulae, hemodynamic monitoring, and immediate evaluation of surgical results and complications.