Perfusion strategy using axillary or femoral cannulation for minimally invasive cardiac surgery: experience in 270 patients with computed tomography-based criteria

Initial experience and favorable outcomes on cannulation strategies and surgical platform construction in fully video-assisted thoracoscopic cardiac surgery

Background

Minimally invasive cardiac surgery offers numerous advantages that patients and surgeons desire. This surgical platform encompasses cannulation strategies for cardiopulmonary bypass, optimal surgical access points, and high-quality visualization techniques. Traditional peripheral cannulation methods, though convenient, possess inherent limitations and carry the potential for complications such as retrograde dissection, stroke, or neurologic sequelae. Conversely, central cannulation may be ideally suited to circumvent the disadvantages above. Fully video-assisted thoracoscopy cardiac surgery represents a state-of-the-art platform, offering surgeons an unparalleled surgical view. This analysis aimed to delineate the efficacy and safety of transthoracic central cannulation strategies and the surgical platform during fully video-assisted thoracoscopy cardiac surgery.

Methods

Between October 2022 and February 2024, we identified a cohort of 85 consecutive patients with cardiopulmonary bypass undergoing fully video-assisted thoracoscopy cardiac surgery at our institutions. The patients' mean age was 41.09 ± 14.01 years, ranging from 18 to 75 years. The mean weight was 64.34 ± 10.59 kg (ranging from 49 to 103 kg). Congenital heart disease repair accounted for the highest proportion, with 43 cases (50.59%). Mitral valve surgery and left atrium Myxoma resections accounted for 29.41%. Specifically, this included 14 mitral valve repairs, five mitral valve replacements, and six left atrium myxoma resections. Aortic valve replacements constitute 20% of all cases.

Results

A total of 85 adult patients underwent fully video-assisted thoracoscopy cardiac surgery. The average CPB time was 83.26 ± 28.26 min, while the aortic cross-clamp time averaged 51.87 ± 23.91 min. The total operation time (skin to skin) averaged 173.8 ± 37.08 min. The mean duration of mechanical ventilation was 5.58 ± 3.43 h, ICU stay was 20.04 ± 2.83 h (ranging from 15.5 to 34 h), and postoperative hospital stay was 5.55 ± 0.87 days. No patients required conversion to thoracotomy and unplanned reoperations due to various reasons. There were no in-hospital deaths, strokes, myocardial infarctions, aortic dissections, or renal failure. No patient developed wound soft tissue infection.

Conclusions

Fully video-assisted thoracoscopy cardiac surgery utilizing central cannulation strategies is a reliable, cost-effective platform with a low risk of complications and a potential solution for patients facing contraindications for peripheral cannulation.

Surgical outcomes of minimally invasive aortic valve replacement via right mini-thoracotomy for hemodialysis patients

OBJECTIVES

Minimally invasive valve surgery has become increasingly accepted as an alternative to conventional median sternotomy in low-risk patients. However, there have been no reports regarding the outcomes of this procedure on high-risk hemodialysis patients. The purpose of this investigation was to assess the surgical outcomes of minimally invasive aortic valve replacement (AVR) via right mini-thoracotomy (MIAVR) in hemodialysis patients compared with those of conventional AVR (CAVR) via full sternotomy.

METHODS

Two hundred and seventy-four patients underwent isolated AVR for severe AS, and 42 hemodialysis patients were included in this study. MIAVR was performed in 17 cases and CAVR in 25 cases. We compared the short-term surgical outcome among the two groups.

RESULTS

There was no difference in the aortic cross-clamp or cardiopulmonary bypass time. However, the procedure time was significantly shorter in the MIAVR group. Patients in the MIAVR group had less bleeding and a smaller amount of transfused red blood cells. There were four hospital deaths (18.2%) in the CAVR group. For postoperative complications, there were 2 (9.1%) cerebrovascular incidents, 2 (9.1%) cases of respiratory failure, 1 (4.5%) re-exploration for bleeding in CAVR group. The postoperative ventilation time was significantly shorter in the MIAVR group. There was no difference in the length of postoperative intensive care unit stay or of postoperative hospital stay.

CONCLUSION

The surgical outcomes of MIAVR in hemodialysis patients were acceptable, with a low incidence of morbidity, reasonable lengths of hospital stay, and no mortality among the patients studied.

A case report of an interrupted inferior vena cava and azygos continuation: implications for preoperative screening in minimally invasive cardiac surgery

Background

Femoral cannulation is commonly used in minimally invasive cardiac surgery to establish extracorporeal circulation. We present a case with a finding that should be evaluated when screening candidates for minimally invasive cardiac surgery.

Case summary

A 57-year-old male patient was scheduled for minimally invasive repair of the mitral and tricuspid valve and a MAZE procedure. During surgery there was difficulty advancing the venous cannula inserted in the right femoral vein. On transoesophageal echocardiography a guidewire advanced from the femoral vein was observed entering the right atrium from the superior vena cava. Despite inserting a second venous cannula in the jugular vein, venous drainage was insufficient for minimal invasive surgery. The approach was converted to a median sternotomy with bicaval cannulation. Re-examination of the preoperative computed tomography (CT) scan showed an interrupted inferior vena cava (IVC) with azygos continuation.

Discussion

In patients with major venous malformations such as the interrupted IVC with azygos continuation a full sternotomy is the preferred approach. The venous system should be evaluated when screening candidates for minimally invasive mitral valve surgery with preoperative CT. Additional cues to suspect interruption of the IVC are polysplenia and a broad superior mediastinal projection on the chest radiograph, mimicking a right paratracheal mass.

Cumulative sum analysis for the learning curve of minimally invasive mitral valve repair

Minimally invasive mitral valve repair, recently, has become an alternative procedure to conventional mitral valve surgery, given its clinical benefits. Understanding the learning curve of a new procedure is important prior to its introduction. This study aimed to evaluate the learning curve for minimally invasive mitral valve repair and safety during the start-up period. The first 100 consecutive patients who underwent isolated minimally invasive mitral valve repair for mitral valve regurgitation were evaluated. The procedure was performed by a single surgeon at a single institution. Calculated cumulative sum analysis and cubic spline curve analysis were performed to evaluate the learning curves for the total procedure (TP), extracorporeal circulation (ECC), and aortic cross-clamping (ACC) times. ACC time was affected by the complexity of individual mitral valve repair; therefore, we analyzed the TP minus ACC (TP-ACC) time as a true learning curve by subtracting the ACC time from the TP time to exclude the difference of the complexity. Additionally, the operative outcome was assessed. Overall, the average TP, ECC, ACC, TP-ACC times were 211 ± 41, 133 ± 35, 108 ± 31, and 104 ± 4.9 min, respectively. All cubic spline curves depicted a decreasing trend, and improvements in TP, ECC, and ACC times were observed after 56 cases, while those of the TP-ACC time were observed after 68 cases. None of the patients experienced hospital mortality, reoperation for bleeding, respiratory failure, cerebral infarction with a disability, or recurrence of mitral valve regurgitation. Acute renal failure occurred in one patient. In conclusion, minimally invasive mitral valve repair can be introduced safely and provide a favorable outcome. However, a learning curve exists for the operative time factors. Approximately 60 operations are required to achieve a consistent operative time.