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Fatehi Hassanabad A, Fercho J, Fatehi Hassanabad M, King M, Sosniuk M, de Waard D, Adams C, Kent WDT, Karolak W. Right anterior mini thoracotomy for redo cardiac surgery: case series from North America and Europe. Front Cardiovasc Med 2024; 11:1427930. [PMID: 38957329 PMCID: PMC11218824 DOI: 10.3389/fcvm.2024.1427930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 06/03/2024] [Indexed: 07/04/2024] Open
Abstract
Background Right anterior mini thoracotomy (RAMT) for aortic valve replacement (AVR) is a minimally invasive procedure that avoids sternotomy. Herein, we report the outcomes of patients who underwent redo-cardiac via a RAMT approach for AVR. Methods This case series reports the clinical outcomes of 14 consecutive redo operations, done in Calgary (Canada) and Gdansk (Poland) between 2020 and 2023. Primary outcomes were 30-day mortality and disabling stroke. Secondary outcomes included surgical times, hemodynamics, permanent pacemaker implantation (PPM), length of ICU and hospital stay, new post-operative atrial fibrillation (POAF), post-operative blood transfusion, incidence of acute respiratory distress syndrome (ARDS), rate of continuous renal replacement therapy (CRRT) and/or dialysis, and chest tube output in the first 12-hours after surgery. Results Nine patients were male, and the mean age was 64.36 years. There were no deaths, while one patient had a disabling stroke postoperatively. Mean cardiopulmonary bypass and cross clamp-times were 136 min and 90 min, respectively. Three patients needed a PPM, 3 patients needed blood transfusions, and 2 developed new onset POAF. Median lengths of ICU and hospital stays were 2 and 12 days, respectively. There was no incidence of paravalvular leak greater than trace and the average transvalvular mean gradient was 12.23 mmHg. Conclusion The number of patients requiring redo-AVR is increasing. Redo-sternotomy may not be feasible for many patients. This study suggests that the RAMT approach is a safe alternative to redo-sternotomy for patients that require an AVR.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Justyna Fercho
- Department of Cardiac Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Mortaza Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Melissa King
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Morgan Sosniuk
- Department of General Internal Medicine, Faculty of Medicine, University of Calgary, Calgary, NS, Canada
| | - Dominique de Waard
- Division of Cardiac Surgery, Nova Scotia Health Authority, Dalhousie University, Halifax, NS, Canada
| | - Corey Adams
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - William D. T. Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Wojtek Karolak
- Department of Cardiac Surgery, Medical University of Gdansk, Gdansk, Poland
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El-Andari R, Fialka NM, Shan S, White A, Manikala VK, Wang S. Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis. Cardiol Rev 2024; 32:217-242. [PMID: 36728720 DOI: 10.1097/crd.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In recent years, minimally invasive cardiac surgery has increased in prevalence. There has been significant debate regarding the optimal approach to isolated aortic valve replacement between conventional midline sternotomy and minimally invasive approaches. We performed a systematic review of the contemporary literature comparing minimally invasive to full sternotomy aortic valve replacement. PubMed and Embase were systematically searched for articles published from 2010-2021. A total of 1215 studies were screened and 45 studies (148,606 patients total) met the inclusion criteria. This study found rates of in-hospital mortality were higher with full sternotomy than ministernotomy ( P = 0.02). 30-day mortality was higher with full sternotomy compared to right anterior thoracotomy ( P = 0.006). Renal complications were more common with full sternotomy versus ministernotomy ( P < 0.00001) and right anterior thoracotomy ( P < 0.0001). Rates of wound infections were greater with full sternotomy than ministernotomy ( P = 0.02) and right anterior thoracotomy ( P < 0.00001). Intensive care unit length of stay ( P = 0.0001) and hospital length of stay ( P < 0.0001) were shorter with ministernotomy compared to full sternotomy. This review found that minimally invasive approaches to isolated aortic valve replacement result in reduced early mortality and select measures of postoperative morbidity; however, long-term mortality is not significantly different based on surgical approach. An analysis of mortality alone is not sufficient for the selection of the optimal approach to isolated aortic valve replacement. Surgeon experience, individual patient characteristics, and preference require thorough consideration, and additional studies investigating quality of life measures will be imperative in identifying the optimal approach to isolated aortic valve replacement.
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Affiliation(s)
- Ryaan El-Andari
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shubham Shan
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Abigail White
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Vinod K Manikala
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Shaohua Wang
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Hamiko M, Salamate S, Nassari MA, Spaeth A, Sirat S, Doss M, Amer M, Silaschi M, Ahmad AES, Bakhtiary F. Totally Endoscopic Replacement of the Ascending Aorta and the Aortic Root including the Aortic Valve via Right Mini-Thoracotomy: A Multicenter Study. J Clin Med 2024; 13:2648. [PMID: 38731177 PMCID: PMC11084888 DOI: 10.3390/jcm13092648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/22/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Recently, minimally invasive access via right anterolateral mini-thoracotomy (RAMT) has been gaining popularity in cardiac surgery. This approach is also an option for surgeons performing aortic surgery. The aim of this study is to present our surgical method, highlighting the total endoscopic minimally invasive approach via RAMT for replacement of the ascending aorta (AAR) with or without involvement of the aortic root and the aortic valve. Methods: Clinical data of 44 patients from three participating institutions with AAR with or without involvement of the aortic valve or aortic root via RAMT between April 2017 and February 2024 were retrospectively analyzed. According to surgical procedure, patients were divided into two groups, in the AAR and in the Wheat/Bentall group with concomitant valve or root replacement. Operative time, length of ventilation, perioperative outcome, length of intensive care unit (ICU) as well as postoperative hospital stay, and mid- and long-term results were retrospectively analyzed. Results: Mean age was 61.4 ± 10.7 years old with a frequency of male gender of 63.6%. Mean cardiopulmonary bypass (CBP) time and aortic cross-clamping time was 94.9 ± 32.5 min and 63.8 ± 25.9 min, respectively. CPB and aortic clamp time were significantly lower in AAR group. In the first 24 h, the mean drainage volume was 790.3 ± 423.6 mL. Re-thoracotomy due to bleeding was zero. Sternotomy was able to be avoided in all patients. Patients stayed 35.9 ± 23.5 h at ICU and were discharged 7.8 ± 3.0 days following surgery from hospital. Mean ventilation time was 5.8 ± 7.6 h. All patients survived and 30-day mortality was 0.0%. At a median follow-up time of 18.2 months, all patients were alive. The results were similar in both groups. Conclusions: The full endoscopic RAMT approach with 3D visualization is a safe, feasible and promising technique that can be transferred in the field of aortic surgery without compromising surgical quality, postoperative outcomes, or patient safety when performed by an experienced team in a high-volume center.
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Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (S.S.); (M.A.N.); (A.S.); (M.S.); (A.E.-S.A.); (F.B.)
| | - Saad Salamate
- Department of Cardiac Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (S.S.); (M.A.N.); (A.S.); (M.S.); (A.E.-S.A.); (F.B.)
| | - Maedeh Ayay Nassari
- Department of Cardiac Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (S.S.); (M.A.N.); (A.S.); (M.S.); (A.E.-S.A.); (F.B.)
| | - Andre Spaeth
- Department of Cardiac Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (S.S.); (M.A.N.); (A.S.); (M.S.); (A.E.-S.A.); (F.B.)
| | - Sami Sirat
- Department of Cardiac Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany; (S.S.); (M.D.)
| | - Mirko Doss
- Department of Cardiac Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany; (S.S.); (M.D.)
| | - Mohamed Amer
- Department of Cardiac Surgery, Helios Hospital Wuppertal, 42283 Wuppertal, Germany;
| | - Miriam Silaschi
- Department of Cardiac Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (S.S.); (M.A.N.); (A.S.); (M.S.); (A.E.-S.A.); (F.B.)
| | - Ali El-Sayed Ahmad
- Department of Cardiac Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (S.S.); (M.A.N.); (A.S.); (M.S.); (A.E.-S.A.); (F.B.)
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany; (S.S.); (M.A.N.); (A.S.); (M.S.); (A.E.-S.A.); (F.B.)
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Taghizadeh-Waghefi A, Arzt S, Wenzel L, Petrov A, Wilbring M, Matschke K, Kappert U, Alexiou K. Right Anterior versus Right Transaxillary Access for Minimally Invasive Aortic Valve Replacement: A Propensity Matched Competitive Analysis. J Clin Med 2024; 13:985. [PMID: 38398297 PMCID: PMC10889463 DOI: 10.3390/jcm13040985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Right anterior thoracotomy (RAT-AVR) has been the sole established sternum-sparing technique for minimally invasive aortic valve replacement (MICS-AVR) thus far. Nevertheless, transaxillary access, known as Minimally Invasive Cardiac LATeral Surgery (MICLATS-AVR), represents the latest and innovative advancement in sternum-sparing MICS-AVR access routes. In this study, procedural and clinical outcomes of a substantial transaxillary MICS-AVR cohort are compared to those of a RAT-AVR control group; (2) Patients and Methods: This retrospective study included 918 consecutive patients who underwent MICS-AVR at our facility between 2014 and 2022. This cohort was divided into two surgical access-related groups: RAT-AVR (n = 492) and MICLATS-AVR (n = 426). Procedural data, operative morbidity, and mortality were compared between groups. Further analysis was performed using propensity score matching; (3) Results: After matching, 359 pairs of patients were included and analyzed. There were no notable differences observed between the two groups regarding major adverse cardio-cerebral events. Despite longer cardiopulmonary bypass time in the MICLATS-AVR group (63.1 ± 20.4 min vs. 66.4 ± 18.2 min; p ≤ 0.001) the skin-to-skin time (129.4 ± 35.9 min. vs. 126.5 ± 29.8 min.; p = 0.790) and the aortic cross-clamp time was comparable between both groups (41.9 ± 13.3 min. vs. 43.5 ± 14.4 min.; p = 0.182). The overall hospital stay was significantly shorter in the MICLATS-AVR cohort (9.7 ± 5.2 days vs. 9.2 ± 4.5 days; p = 0.01). Both groups were comparable in terms of postoperative morbidities. However, significantly lower rates of postoperative impaired wound healing were noted in the MICLATS-AVR group (11.7% vs. 3.9%, p < 0.001); (4) Conclusions: In comparing MICLATS-AVR and RAT-AVR, our study found MICLATS-AVR to be at least as safe and time-efficient as RAT-AVR, with no significant differences in MACCE. MICLATS-AVR showed a shorter hospital stay and lower postoperative wound issues, indicating its feasibility and safety as an alternative. Notably, MICLATS-AVR is sternum- and bone-sparing, preserving the right mammary artery, and facilitates combined procedures like multiple valve surgeries.
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Affiliation(s)
- Ali Taghizadeh-Waghefi
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Sebastian Arzt
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Lisa Wenzel
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Asen Petrov
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Manuel Wilbring
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Klaus Matschke
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Utz Kappert
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Konstantin Alexiou
- Medical Faculty “Carl Gustav Carus”, TU Dresden, 01307 Dresden, Germany; (S.A.); (A.P.); (M.W.); (K.M.); (U.K.); (K.A.)
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
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Yang NK, Soliman FK, Pepe RJ, Palte NK, Yoo J, Nithikasem S, Laraia KN, Chakraborty A, Chao JC, Sunagawa G, Takebe M, Lemaire A, Ikegami H, Russo MJ, Lee LY. Minimally invasive approach associated with lower resource utilization after aortic and mitral valve surgery. JTCVS OPEN 2023; 15:72-80. [PMID: 37808048 PMCID: PMC10556938 DOI: 10.1016/j.xjon.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/21/2023] [Accepted: 06/05/2023] [Indexed: 10/10/2023]
Abstract
Objective To investigate the effect of minimally invasive cardiac surgery (MICS) on resource utilization, cost, and postoperative outcomes in patients undergoing left-heart valve operations. Methods Data were retrospectively reviewed for patients undergoing single-valve surgery (eg, aortic valve replacement, mitral valve replacement, or mitral valve repair) at a single center from 2018 to 2021, stratified by surgical approach: MICS vs full sternotomy (FS). Baseline characteristics and postoperative outcomes were compared. Primary outcome was high resource utilization, defined as direct procedure cost higher than the third quartile or either postoperative LOS ≥7 days or 30-day readmission. Secondary outcomes were direct cost, length of stay, 30-day readmission, in-hospital and 30-day mortality, and major morbidity. Multiple regression analysis was conducted, controlling for baseline characteristics, operative approach, valve operation, and lead surgeon to assess high resource utilization. Results MICS was correlated with a significantly lower rate of high resource utilization (MICS, 31.25% [n = 115] vs FS 61.29% [n = 76]; P < .001). Median postoperative length of stay (MICS, 4 days [range, 3-6 days] vs FS, 6 days [range, 4 to 9 days]; P < .001) and direct cost (MICS, $22,900 [$19,500-$28,600] vs FS, $31,900 [$25,900-$50,000]; P < .001) were lower in the MICS group. FS patients were more likely to experience postoperative atrial fibrillation (P = .040) and renal failure (P = .027). Other outcomes did not differ between groups. Controlling for stratified Society of Thoracic Surgeons predicted risk of mortality, cardiac valve operation, and lead surgeon, FS demonstrated increased likelihood of high resource utilization (P < .001). Conclusions MICS for left-heart valve pathology demonstrated improved postoperative outcomes and resource utilization.
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Affiliation(s)
- NaYoung K. Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Fady K. Soliman
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Russell J. Pepe
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Nadia K. Palte
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jin Yoo
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sorasicha Nithikasem
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Kayla N. Laraia
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Abhishek Chakraborty
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Joshua C. Chao
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Gengo Sunagawa
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Manabu Takebe
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Hirohisa Ikegami
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Mark J. Russo
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Leonard Y. Lee
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
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Abdelaal SA, Abdelrahim NA, Mamdouh M, Ahmed N, Ahmed TR, Hefnawy MT, Alaqori LK, Abozaid M. Comparative effects of minimally invasive approaches vs. conventional for obese patients undergoing aortic valve replacement: a systematic review and network meta-analysis. BMC Cardiovasc Disord 2023; 23:392. [PMID: 37559011 PMCID: PMC10413702 DOI: 10.1186/s12872-023-03410-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/22/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Minimally invasive approaches like mini-thoracotomy and mini-sternotomy for Aortic Valve Replacement (AVR) showed impressive outcomes. However, their advantages for obese patients are questionable. We aimed in this network meta-analysis to compare three surgical approaches: Full sternotomy (FS), Mini-sternotomy (MS), and Mini-thoracotomy (MT) for obese patients undergoing AVR. METHODS We followed the PRISMA extension for this network meta-analysis. PubMed/Medline, Scopus, Web of Science, and Cochrane searched through March 2023 for relevant articles. The analysis was performed using R version 4.2.3. RESULTS Out of 344, 8 articles met the criteria with 1392 patients. The main outcomes assessed were perioperative mortality, re-exploration, atrial fibrillation, renal failure, ICU stay, hospital stay, cross-clamp time, and bypass time. In favor of MS, the length of ICU stay and hospital stay was significantly lower than for FS [MD -0.84, 95%CI (-1.26; -0.43)], and [MD -2.56, 95%CI (-3.90; -1.22)], respectively. Regarding peri-operative mortality, FS showed a significantly higher risk compared to MS [RR 2.28, 95%CI (1.01;5.16)]. Also, patients who underwent minimally invasive approaches; MT and MS, required less need of re-exploration compared to FS [RR 0.10, 95%CI (0.02;0.45)], and [RR 0.33, 95%CI (0.14;0.79)], respectively. However, Intraoperative timings; including aortic cross-clamp, and cardiopulmonary bypass time, were significantly lower with FS than for MS [MD -9.16, 95%CI (-1.88; -16.45)], [MD -9.61, 95%CI (-18.64; -0.59)], respectively. CONCLUSION Our network meta-analysis shows that minimally invasive approaches offer some advantages for obese patients undergoing AVR over full sternotomy. Suggesting that these approaches might be considered more beneficial alternatives for obese patients undergoing AVR.
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Affiliation(s)
| | | | | | - Nour Ahmed
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
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7
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Gerfer S, Eghbalzadeh K, Brinkschröder S, Djordjevic I, Rustenbach C, Rahmanian P, Mader N, Kuhn E, Wahlers T. Is It Reasonable to Perform Isolated SAVR by Residents in the TAVI Era? Thorac Cardiovasc Surg 2023; 71:376-386. [PMID: 34808679 DOI: 10.1055/s-0041-1736206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The role of conventional surgical aortic valve replacement (SAVR) is increasingly questioned since the indication for transcatheter aortic valve implantations (TAVIs) is currently extended. While the number of patients referred to SAVR decreases, it is unclear if SAVR should be performed by junior resident surgeons in the course of a heart surgeons training. METHODS Patients with isolated aortic valve replacement (AVR) were analyzed with respect to the surgeon's qualification. AVR performed by resident surgeons was compared with AVR by senior surgeons. The collective was analyzed with respect to clinical short-term outcomes comparing full sternotomy (FS) with minimally invasive surgery and ministernotomy (MS) with right anterior thoracotomy (RAT) after a 1:1 propensity score matching. RESULTS The 30-day all-cause mortality was 2.3 and 3.4% for resident versus senior AVR groups, cerebrovascular event rates were 1.1 versus 2.6%, and no cases of significant paravalvular leak were detected. Clinical short-term outcomes between FS and minimally invasive access, as well after MS and RAT were comparable. CONCLUSION Our current data show feasibility and safety of conventional SAVR procedure performed by resident surgeons in the era of TAVI. Minimally invasive surgery should be trained and performed in higher volumes early in the educational process as it is a safe treatment option.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Sarah Brinkschröder
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
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Vohra HA, Salmasi MY, Mohamed F, Shehata M, Bahrami B, Caputo M, Deshpande R, Bapat V, Bahrami T, Birdi I, Zacharias J. Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting. Open Heart 2023; 10:e002194. [PMID: 37001910 PMCID: PMC10069572 DOI: 10.1136/openhrt-2022-002194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/27/2023] [Indexed: 04/04/2023] Open
Abstract
The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.
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Affiliation(s)
| | | | | | | | | | | | | | - Vinayak Bapat
- Cardiovascular Directorate, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Inderpaul Birdi
- Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Joseph Zacharias
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
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Jovanovic M, Zivkovic I, Jovanovic M, Bilbija I, Petrovic M, Markovic J, Radovic I, Dimitrijevic A, Soldatovic I. Economic Justification Analysis of Minimally Invasive versus Conventional Aortic Valve Replacement. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2553. [PMID: 36767915 PMCID: PMC9916198 DOI: 10.3390/ijerph20032553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
There is no definitive consensus about the cost-effectiveness of minimally invasive aortic valve replacement (AVR) (MI-AVR) compared to conventional AVR (C-AVR). The aim of this study was to compare the rate of postoperative complications and total hospital costs of MI-AVR versus C-AVR overall and by the type of aortic prosthesis (biological or mechanical). Our single-center retrospective study included 324 patients over 18 years old who underwent elective isolated primary AVR with standard stented AV prosthesis at the Institute for Cardiovascular Diseases "Dedinje" between January 2019 and December 2019. Reintervention, emergencies, combined surgical interventions, and patients with sutureless valves were excluded. In both MI-AVR and C-AVR, mechanical valve implantation contributed to overall reduction of hospital costs with equal efficacy. The cost-effectiveness ratio indicated that C-AVR is cheaper and yielded a better clinical outcome with mechanical valve implantation (67.17 vs. 69.5). In biological valve implantation, MI-AVR was superior. MI-AVR patients had statistically significantly higher LVEF and a lower Euro SCORE than C-AVR patients (Mann-Whitney U-test, p = 0.002 and p = 0.002, respectively). There is a slight advantage to MI-AVR vs. C-AVR, since it costs EUR 9.44 more to address complications that may arise. Complications (mortality, early reoperation, cerebrovascular insult, pacemaker implantation, atrial fibrillation, AV block, systemic inflammatory response syndrome, wound infection) were less frequent in the MI-AVR, making MI-AVR more economically justified than C-AVR (18% vs. 22.1%).
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Affiliation(s)
- Marko Jovanovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Zivkovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Milos Jovanovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
| | - Ilija Bilbija
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Cardiac Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Masa Petrovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jovan Markovic
- Faculty of Dental Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Radovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Transfusiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ana Dimitrijevic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivan Soldatovic
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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10
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Telyuk P, Hancock H, Maier R, Batty JA, Goodwin A, Owens WA, Ogundimu E, Akowuah E. Long-term outcomes of mini-sternotomy versus conventional sternotomy for aortic valve replacement: a randomized controlled trial. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6832043. [PMID: 36394261 DOI: 10.1093/ejcts/ezac540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/06/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Aortic valve replacement (AVR) for severe symptomatic aortic stenosis is one of the most common cardiac surgical procedures with excellent long-term outcomes. Multiple previous studies have compared short-term outcomes of AVR with mini-sternotomy versus AVR with conventional sternotomy. We have previously reported the results of the randomized MAVRIC trial, which aimed to evaluate early postoperative morbidity among patients undergoing mini-sternotomy and conventional sternotomy AVR. We now report the long-term all-cause mortality, reoperation, MACE outcomes and echocardiographic data from this trial. METHODS The prospective, randomized, single-centre, single-blind MAVRIC (manubrium-limited mini-sternotomy versus conventional sternotomy for aortic valve replacement) trial compared manubrium-limited mini-sternotomy and conventional median sternotomy for the treatment of patients with severe aortic stenosis. The previously reported primary outcome was the proportion of patients receiving red cell transfusion postoperatively and within 7 days of the index procedure. Currently reported exploratory analyses of a combined long-term all-cause mortality and reoperation were compared between groups via the log-rank test. Sensitivity analyses reviewed individual components of the combined end point. The primary analysis and long-term exploratory analyses were based on an intention-to-treat principle. RESULTS Between March 2014 and June 2016, 270 patients were enrolled and randomized in a 1:1 fashion to undergo mini-sternotomy AVR (n = 135) or conventional median sternotomy AVR (n = 135). At the median follow-up of 6.1 years, the composite outcome of all-cause mortality and reoperation occurred in 18.5% (25/135) of patients in the conventional sternotomy group and in 17% (23/135) of patients in the mini-sternotomy group. The incidence of chronic kidney disease, cerebrovascular accident and myocardial infarction was not significantly different between 2 groups. Follow-up echocardiographic data suggested no difference in peak and mean gradients or incidence of aortic regurgitation between 2 approaches. CONCLUSIONS This exploratory long-term analysis demonstrated that, in patients with severe aortic stenosis undergoing isolated AVR, there was no significant difference between manubrium-limited mini-sternotomy and conventional sternotomy with respect to all-cause mortality, rate of reoperation, MACE events and echocardiographic data at the median of 6.1-year follow-up.
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Affiliation(s)
- Pyotr Telyuk
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | - Helen Hancock
- Newcastle Clinical Trials Unit, Newcastle upon Tyne, UK
| | - Rebecca Maier
- Newcastle Clinical Trials Unit, Newcastle upon Tyne, UK
| | - Jonathan A Batty
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | - Andrew Goodwin
- Department of Cardiovascular Surgery, The James Cook University Hospital, Middlesbrough, UK
| | - W Andrew Owens
- Department of Cardiovascular Surgery, The James Cook University Hospital, Middlesbrough, UK
| | | | - Enoch Akowuah
- Department of Cardiovascular Surgery, The James Cook University Hospital, Middlesbrough, UK
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11
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Ji Q, Wang Y, Liu F, Yang Y, Li J, Sun X, Yang Z, Pan S, Lai H, Wang C. Mini-Invasive Bentall Procedure Performed via a Right Anterior Thoracotomy Approach With a Costochondral Cartilage Sparing. Front Cardiovasc Med 2022; 9:841472. [PMID: 35310990 PMCID: PMC8924284 DOI: 10.3389/fcvm.2022.841472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/08/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives A right minithoracotomy approach with a sternal sparing technique is a minimally invasive option for surgeons performing aortic root surgery. This report presents our initial clinical results of the right minithoracotomy Bentall procedure. Methods Clinical data of 15 patients were retrospectively analyzed who underwent the minimally invasive Bentall procedure through the right anterior thoracotomy via the second intercostal incision without any costochondral cartilage invasion at our institution between October, 2019 and June, 2021. The operative time, length of intensive care unit stay and postoperative hospital stay, perioperative outcomes, and follow-up results were analyzed. Results The median aortic cross-clamping time was 95.0 (85.5–98.8) min. Three (21.4%) patients received blood transfusion. The median drainage volume in the first 24 h was 200.0 ml, with no redo for bleeding. The median duration of mechanical ventilation was 12.5 (11.0–25.0) h, and median length of intensive care unit stay was 1.5 (1.0–3.0) day. All patients discharged 5.8 ± 1.2 days following surgery, with no dead patients found. At 6 months following surgery, all patients survived with an improved New York Heart Association (NYHA) functional class. Conclusion The right minithoracotomy Bentall procedure may be performed safely with low morbidity and mortality. This approach should be considered as an option in carefully selected patients requiring aortic root replacement.
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Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - YuLin Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - FangYu Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ye Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - XiaoNing Sun
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - ZhaoHua Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Sun Pan
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Hao Lai,
| | - ChunSheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Municipal Institute for Cardiovascular Diseases, Shanghai, China
- ChunSheng Wang,
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12
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Jawarkar M, Manek P, Wadhawa V, Doshi C. Mini-Bentall Surgery: The Right Thoracotomy Approach. J Chest Surg 2021; 54:554-557. [PMID: 34667134 PMCID: PMC8646065 DOI: 10.5090/jcs.21.036] [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: 04/27/2021] [Revised: 07/05/2021] [Accepted: 08/05/2021] [Indexed: 11/16/2022] Open
Abstract
Surgeons are increasingly using the right mini-thoracotomy approach to perform aortic valve surgery. This approach has shown better results in terms of blood loss and length of hospital stay than the sternotomy approach. For selected patients requiring aortic root and ascending aorta surgery, a right mini-thoracotomy approach may prove beneficial. In our technique, we placed a 5-cm horizontal skin incision in the right second intercostal space. Femoro-femoral cardiopulmonary bypass was established. A valved aortic conduit was used for aortic root replacement. The patient’s postoperative course was uneventful, with a short hospital stay. This technique offers a minimally invasive approach to aortic root and ascending aorta surgery with easy adaptability and reduced costs.
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Affiliation(s)
- Manish Jawarkar
- Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, B. J. Medical College, Ahmedabad, India
| | - Pratik Manek
- Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, B. J. Medical College, Ahmedabad, India
| | - Vivek Wadhawa
- Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, B. J. Medical College, Ahmedabad, India
| | - Chirag Doshi
- Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, B. J. Medical College, Ahmedabad, India
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13
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Zubarevich A, Zhigalov K, Schmack B, Rad AA, Vardanyan R, Wendt D, Ruhparwar A, Weymann A. Step-by-Step Minimally Invasive Aortic Valve Replacement: the RAT Approach. Braz J Cardiovasc Surg 2021; 36:420-423. [PMID: 33577265 PMCID: PMC8357396 DOI: 10.21470/1678-9741-2020-0393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
In the growing era of transcatheter aortic valve implantation, it is crucial to develop minimally invasive surgical techniques. These methods enable easier recovery from surgical trauma, especially in elderly and frail patients. Minimally invasive aortic valve replacement (MIAVR) is frequently performed via upper hemisternotomy. We describe MIAVR via right anterior thoracotomy, which is associated with less trauma, rapid mobilization, lower blood transfusion rates, and lower risk of postoperative wound infections. As minimally invasive procedures tend to take longer operative times, we suggest using rapid-deployment valve prostheses to overcome this limitation. This description focuses on the technical aspects and preoperative assessment.
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Affiliation(s)
- Alina Zubarevich
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Konstantin Zhigalov
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Arian Arjomani Rad
- Department of Medicine, Faculty of Medicine, Imperial College London, Great Britain
| | - Robert Vardanyan
- Department of Medicine, Faculty of Medicine, Imperial College London, Great Britain
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
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14
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Richter G, Van Praet KM, Hommel M, Sündermann SH, Kofler M, Meyer A, Unbehaun A, Starck C, Jacobs S, Falk V, Kempfert J. SLL-PEEP Ventilation to Improve Exposure in Minimally Invasive Right Anterolateral Minithoracotomy Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:358-364. [PMID: 33877924 DOI: 10.1177/15569845211004265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE An accepted landmark to assess feasibility of surgical aortic valve replacement (SAVR) via right anterolateral minithoracotomy (RALT) is the aortic-midpoint to right-sternal-edge distance. We aimed to evaluate single left lung positive-end-expiratory-pressure (SLL-PEEP) ventilation inducing an intraoperative rightward shift of the ascending aorta to improve exposure. METHODS Nineteen patients with aortic stenosis undergoing SAVR via RALT were prospectively analyzed. SLL-PEEP ventilation (20,395 cmH2O) via a double-lumen endotracheal tube was applied immediately before transthoracic aortic cross-clamping, thereby inducing rightward shift of the ascending aorta to enhance exposure. We analyzed preoperative computed tomography (CT) reconstructions and intraoperative video recordings. Primary endpoint was extent of rightward shift induced by SLL-PEEP ventilation; secondary endpoints were procedure times and safety events. RESULTS Mean age was 61 ± 14.8 years and 6 of 19 (31.6%) were female. Mean EuroSCORE II was 0.81% ± 0.04%, STS-PROM was 1.13% ± 0.74%, and mean aortic rightward shift induced by SLL-PEEP ventilation was 10.32 ± 4.14 mm (4 to 17 mm; P = 0.003). Median shift in the group considered suitable for the RALT approach by preoperative CT-scan evaluation was 14.2 mm (IQR 11) and in the less suitable group 11.5 mm (IQR 5). Mean procedure time was 167 ± 28.9 min, CPB time was 105.7 ± 18.4 min, and cross-clamp time was 64.5 ± 13 min. Fifteen patients (79%) received SAVR via RALT with implantation of a bioprosthesis, whereas a rapid-deployment-prosthesis was used in 4 patients (21%). Ten of 19 (53%) patients who were classified as less suitable preoperatively received SAVR via RALT after SLL-PEEP ventilation. No strokes were observed. CONCLUSIONS The SLL-PEEP ventilation maneuver during SAVR via RALT significantly enhances aortic exposure. There were no safety events associated with this maneuver and we were able to demonstrate significant rightward aortic shift in every single patient.
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Affiliation(s)
- Gregor Richter
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Karel M Van Praet
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Matthias Hommel
- Department of Anaesthesiology, German Heart Center Berlin, Germany
| | - Simon H Sündermann
- Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin, Germany
| | - Markus Kofler
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Alexander Meyer
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Berlin Institute of Health (BIH), Germany
| | - Axel Unbehaun
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Christoph Starck
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Stephan Jacobs
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Volkmar Falk
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin, Germany.,Berlin Institute of Health (BIH), Germany.,Department of Health Sciences, ETH Zürich, Translational Cardiovascular Technologies, Switzerland
| | - Jörg Kempfert
- 14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
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15
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Di Bacco L, Rosati F, Folliguet T, Petruccelli RD, Concistrè G, Santarpino G, Di Bartolomeo R, Bisleri G, Fischlein TJ, Muneretto C. Sutureless aortic valves in elderly patients with aortic stenosis and intermediate-risk profile. J Cardiovasc Med (Hagerstown) 2021; 22:297-304. [PMID: 33633045 DOI: 10.2459/jcm.0000000000001120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS Sutureless valves became an alternative to standard bioprostheses, allowing surgeons to significantly reduce cross-clamping and extracorporeal circulation times, with a potential positive impact on major postoperative complications. The aim of this European multicentre study was to evaluate the safety and efficacy of sutureless valves in patients with an intermediate-risk profile undergoing aortic valve replacement (AVR). METHODS We investigated early and mid-term outcomes of 518 elderly patients with aortic stenosis at intermediate-risk profile (mean STS Score 6.1 ± 2%) undergoing AVR with sutureless aortic valve. Primary endpoints were 30-day mortality and freedom from all-cause death at follow-up. The secondary endpoint was survival freedom from MACCEs [all-cause death, stroke/transitory ischemic attack (TIA), bleeding, myocardial infarction, aortic regurgitation Grade II, endocarditis, reintervention and pacemaker implant; VARC 1--2 criteria]. RESULTS Sutureless valve implantation was successfully performed in 508 patients, with a procedural success rate of 98.1% (508/518) as per VARC criteria. Concomitant myocardial revascularization [coronary artery bypass grafting (CABG)] was performed in 74 out of 518 patients (14.3%). In-hospital mortality was 1.9% (10/518). Postoperative complications included revision for bleeding (23/518; 4.4%), prolonged intubation more than 48h (4/518; 0.7%), acute renal failure (14/518; 2.7%), stroke/TIA (11/518; 2.1%), pacemaker implantation (26/518; 5.1%) and aortic regurgitation more than Grade II (7/518; 1.4%). At 48-month follow-up, Kaplan-Meier overall survival and freedom from MACCEs in patients receiving isolated AVR were 83.7% [95% confidence interval (95% CI): 81.1-86.3] and 78.4% (95% CI: 75.5-81.4), respectively, while in patients with concomitant CABG, Kaplan-Meier overall survival and freedom from MACCEs were 82.3% (95% CI: 73.3-91.3) and 79.1% (95% CI: 69.9-88.3), respectively. CONCLUSION The use of sutureless aortic valves in elderly patients with an intermediate-risk profile provided excellent early and mid-term outcomes, providing a reliable tool in patients undergoing surgical AVR in this specific subset of population. These preliminary data need to be investigated with a TAVI control-group in further studies.
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Affiliation(s)
- Lorenzo Di Bacco
- Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy
| | - Fabrizio Rosati
- Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy
| | | | - Rocco D Petruccelli
- Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy
| | | | - Giuseppe Santarpino
- Città di Lecce Hospital, GVM Care and Research, Lecce, Italy
- Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | | | - Gianluigi Bisleri
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | | | - Claudio Muneretto
- Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy
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16
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Doyle MP, Woldendorp K, Ng M, Vallely MP, Wilson MK, Yan TD, Bannon PG. Minimally-invasive versus transcatheter aortic valve implantation: systematic review with meta-analysis of propensity-matched studies. J Thorac Dis 2021; 13:1671-1683. [PMID: 33841958 PMCID: PMC8024828 DOI: 10.21037/jtd-20-2233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods. Methods Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis. Results Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37–1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13–1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16–0.52, P<0.0001) and postoperative aortic insufficiency (AI) or paravalvular leak (PVL) (OR 0.05, 95% CI, 0.01–0.20, P<0.0001) compared to TAVI, (OR 0.42, 95% CI, 0.13–1.29, P=0.13), while acute kidney injury (AKI) was higher in MiAVR compared to TAVI (11.1% vs. 5.2%, OR 2.28, 95% CI, 1.25–4.16, P=0.007). Conclusions In patients of equivalent surgical risk scores, MiAVR may be performed with lower rates of postoperative PPM requirement and AI/PVL, higher rates of AKI and no statistical difference in postoperative stroke or short-term mortality, compared to TAVI. Further prospective trials are needed to validate these results.
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Affiliation(s)
- Mathew P Doyle
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,University of Wollongong School of Medicine, Keiraville, Australia
| | - Kei Woldendorp
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | - Martin Ng
- The Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | | | - Michael K Wilson
- Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Royal Prince Alfred Hospital, Sydney, Australia.,Macquarie University Hospital, Macquarie University, Sydney, Australia.,Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Paul G Bannon
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
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17
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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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18
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Lu F, Zhu SQ, Long X, Lin K, Qiu BQ, Pei X, Xu JJ, Wu YB. Clinical study of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision: The first Chinese experience. Asian J Surg 2021; 44:1063-1068. [PMID: 33622599 DOI: 10.1016/j.asjsur.2021.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/01/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is an increasing demand for minimally invasive aortic valve replacement. This study aimed to investigate the safety and feasibility of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision. METHODS This was a retrospective study, and we collected information from 111 patients who underwent isolated aortic valve replacement surgery performed by the same surgeon from January 2018 to December 2019. According to the operative approach, the patients were divided into a sternotomy aortic valve replacement (SAVR) group (n = 62) and a minimally invasive aortic valve replacement (Mini-AVR) group (n = 49). We compared the intraoperative and postoperative data between the two groups. RESULT There was no difference in preoperative data between the Mini-AVR and SAVR. The postoperative ventilator-assisted time, CSICU time and postoperative hospital stay of the Mini-AVR were shorter than those of the SAVR [(15.45 ± 5.75) VS (18.51 ± 6.71) h; (1.77 ± 0.31) VS (2.04 ± 0.63) d; (8.69 ± 2.75) VS (10.77 ± 2.94) d], and the difference was statistically significant (P < 0.05). Mini-AVR had lower postoperative drainage and blood transfusion rates in the first 24 h than SAVR [(109.86 ± 125.98) VS (508.84 ± 311.70) ml; 22.4% VS 46.8%], and the differences were statistically significant (P < 0.05). The incidence of postoperative AF in the Mini-AVR group was also lower than that in the SAVR group (10.2% VS 30.6%), and the differences were statistically significant (P < 0.05). CONCLUSION Mini-AVR has the advantages of less ventilator time, a reduced need for blood transfusion, less AF and a faster recovery. Mini-AVR is a safe and feasible surgical technique that is worthy of clinical application.
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Affiliation(s)
- Feng Lu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Shu-Qiang Zhu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Xiang Long
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Kun Lin
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Bai-Quan Qiu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Xu Pei
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Jian-Jun Xu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Yong-Bing Wu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, PR China.
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19
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Meyer A, van Kampen A, Kiefer P, Sündermann S, Van Praet KM, Borger MA, Falk V, Kempfert J. Minithoracotomy versus full sternotomy for isolated aortic valve replacement: Propensity matched data from two centers. J Card Surg 2020; 36:97-104. [PMID: 33135258 DOI: 10.1111/jocs.15177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/22/2020] [Accepted: 08/31/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Minimally invasive approaches to isolated aortic valve replacement (AVR) continue to gain popularity. This study compares outcomes of AVR through right anterolateral thoracotomy (RALT) to those of AVR through full median sternotomy (MS). METHODS Outcomes of two propensity-matched groups of 85 each, out of 250 patients that underwent isolated AVR through RALT or MS at our two institutions, were compared in a retrospective study. RESULTS Propensity score matching resulted in 85 matched pairs with balanced preoperative characteristics. Procedure times were significantly shorter in the RALT group (median difference: 13 min [-25 to -0.5]; p = .039), cardiopulmonary bypass times were longer (median difference: 17 min [10-23.5]; p = < .001) and ventilation times shorter (median difference: 259 min [-390 to -122.5]; p = < .001). There was no significant difference in aortic cross-clamp times (median difference: 1.5 min [-3.5 to 6.5]; p = .573). The RALT group had lower rates of perioperative platelet transfusions (odds ratio [OR] = 0.00 [0.00-0.59]; p = .0078) and postoperative pneumonia (OR = 0.10 [0.00-0.70]; p = .012), as well as shorter hospitalization times (median difference: 2.5 days [-4.5 to -1]; p = .005). There were no significant differences regarding paravalvular leakage (p = .25), postoperative stroke (p = 1), postoperative atrial fibrillation (p = .12) or 1-year-mortality (p = 1). CONCLUSIONS This study found RALT to be an equally safe approach to surgical AVR as MS. Furthermore, RALT showed advantages regarding important aspects of postoperative recovery, especially concerning pulmonary function.
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Affiliation(s)
- Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Berlin Institute for Foundations of Learning and Data, Berlin, Germany
| | - Antonia van Kampen
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Philipp Kiefer
- University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Simon Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Michael A Borger
- University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
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20
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Woldendorp K, Doyle MP, Bannon PG, Misfeld M, Yan TD, Santarpino G, Berretta P, Di Eusanio M, Meuris B, Cerillo AG, Stefàno P, Marchionni N, Olive JK, Nguyen TC, Solinas M, Bianchi G. Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis. Ann Cardiothorac Surg 2020; 9:347-363. [PMID: 33102174 DOI: 10.21037/acs-2020-surd-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. Methods Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. Results Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. Conclusions Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.
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Affiliation(s)
- Kei Woldendorp
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mathew P Doyle
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Misfeld
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Tristan D Yan
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Adventist Hospital, Sydney, Australia
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.,Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany.,Department of Clinical and Experimental Medicine, Magna Graecia University, Catanzaro, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Pierluigi Stefàno
- Unit of Cardiac Surgery, Careggi University Hospital, Florence, Italy.,University of Florence School of Medicine, Florence, Italy
| | - Niccolò Marchionni
- University of Florence School of Medicine, Florence, Italy.,Unit of Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Heart and Vascular Institute, Houston, Texas, USA
| | - Marco Solinas
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
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21
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Karangelis D, Loggos S, Mitropoulos FA. Right Anterior Mini-Thoracotomy for Discrete Fibromembranous Subaortic Stenosis. World J Pediatr Congenit Heart Surg 2020; 11:664-665. [PMID: 32853081 DOI: 10.1177/2150135120932520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Discrete fibromembranous subaortic stenosis is a common type of subaortic stenosis causing clinically significant left ventricular outflow obstruction. Surgery for discrete subaortic stenosis is most often performed through a typical midline sternotomy. Herein, we present our experience with an adult patient who underwent a right mini-thoracotomy for subaortic membrane resection with central cannulation under direct operative vision.
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Affiliation(s)
- Dimos Karangelis
- Department of Cardiac Surgery, 69036Mitera Hospital, Athens, Greece
| | - Spiros Loggos
- Department of Cardiac Surgery, 69036Mitera Hospital, Athens, Greece
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22
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Van Praet KM, van Kampen A, Kofler M, Richter G, Sündermann SH, Meyer A, Unbehaun A, Kurz S, Jacobs S, Falk V, Kempfert J. Minimally invasive surgical aortic valve replacement: The RALT approach. J Card Surg 2020; 35:2341-2346. [PMID: 32643836 DOI: 10.1111/jocs.14756] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Less-invasive techniques for cardiothoracic surgical procedures are designed to limit surgical trauma, but the technical requirements and preoperative planning are more demanding than those for conventional sternotomy. Patient selection, interdisciplinary collaboration, and surgical skills are key factors for procedural success. Aortic valve replacement is frequently performed through an upper hemisternotomy, but the right anterior minithoracotomy represents an even less traumatic, technical advancement. Preoperative assessment of the ascending aorta in relation to the sternum is mandatory to select patients and the intercostal access site. This description of the surgical technique focuses on the specific procedural details including the obligatory planning with computed tomography and our cannulation strategy. We also sought to define the anatomical ascending aorta-sternal relationship, as it is of utmost importance in preoperative computed tomographic planning.
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Affiliation(s)
- Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Antonia van Kampen
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Gregor Richter
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Simon H Sündermann
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Institute of Health (BIH), Berlin, Germany
| | - Axel Unbehaun
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Stephan Kurz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Institute of Health (BIH), Berlin, Germany.,Department of Health Sciences, Translational Cardiovascular Technologies, ETH Zürich, Zürich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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23
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Sabry H, Baltabaeva A, Gkikas A, Valencia O, Sarri G, Mirsadraee S, Mittal T, Bahrami T. Rapid deployment aortic valve replacement through anterior right thoracotomy: Clinical outcomes and haemodynamic performance. J Card Surg 2020; 35:1420-1424. [PMID: 32340065 DOI: 10.1111/jocs.14585] [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] [Indexed: 11/27/2022]
Abstract
BACKGROUND The ease of implantation of the rapid deployment (RD) and sutureless valves has contributed to the adoption of anterior right thoracotomy (ART) approach for aortic valve replacement (AVR). AIM OF THE STUDY This study evaluates the safety and haemodynamic performance of minimally invasive AVR through ART using the RD valves. METHODS This is a retrospective, single-center review of a total of 50 consecutive patients who received RD-AVR through ART. RESULTS The median age of patients was 75 years (interquartile range [IQR]: 69-80), and median Euroscore II was 5.1 (IQR: 2.4-7.5). ART RD-AVR was successfully performed in all cases with no conversion to sternotomy, paravalvular leaks or need for valve explantation. The mean size of the implanted valve was 23.2 ± 2.3 mm. In-hospital mortality was 2%. The mean and maximum pressure gradients across the aortic prosthesis were 10 mm Hg (IQR: 9-12) and 19 mm Hg (IQR: 16-23). CONCLUSIONS Rapid deployment aortic valve replacement can be safely performed through anterior right thoracotomy wit excellent haemodynamic performance and low postoperative complications rate.
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Affiliation(s)
- Haytham Sabry
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield Trust, Harefield Hospital, London, UK
| | - Aigul Baltabaeva
- Department of Cardiology, Royal Brompton and Harefield Trust, Harefield Hospital, London, UK
| | - Andreas Gkikas
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield Trust, Harefield Hospital, London, UK
| | - Oswaldo Valencia
- Department of Cardiothoracic Surgery, St George's University Hospital, London, UK
| | - Georgia Sarri
- Department of Cardiology, Royal Brompton and Harefield Trust, Harefield Hospital, London, UK
| | - Saeed Mirsadraee
- Department of Radiology, Royal Brompton and Harefield Trust, Harefield Hospital, London, UK
| | - Tarun Mittal
- Department of Radiology, Royal Brompton and Harefield Trust, Harefield Hospital, London, UK
| | - Toufan Bahrami
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield Trust, Harefield Hospital, London, UK
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24
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Paparella D, Malvindi PG, Santarpino G, Moscarelli M, Guida P, Fattouch K, Margari V, Martinelli L, Albertini A, Speziale G. Full sternotomy and minimal access approaches for surgical aortic valve replacement: a multicentre propensity-matched study. Eur J Cardiothorac Surg 2020; 57:709-716. [PMID: 31647535 DOI: 10.1093/ejcts/ezz286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/31/2019] [Accepted: 09/11/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Surgical aortic valve replacement (AVR) can be performed via a full sternotomy or a minimal access approach (mini-AVR). Despite long-term experience with the procedure, mini-AVR is not routinely adopted. Our goal was to compare contemporary outcomes of mini-AVR and conventional AVR in a large multi-institutional national cohort. METHODS A total of 5801 patients from 10 different centres who had a mini-AVR (2851) or AVR (2950) from 2011 to 2017 were evaluated retrospectively. Standard aortic prostheses were used in all cases. The use of the minimally invasive approach has increased over the years. The primary outcome is the incidence of 30-day deaths following mini-AVR and AVR. Secondary outcomes are the occurrence of major complications following both procedures. Propensity-matched comparisons were performed based on the multivariable logistic regression model. RESULTS In the overall population patients who had AVR had an increased surgical risk based on the EuroSCORE, and the 30-day mortality rate was higher (1.5% and 2.3% in mini-AVR and AVR, respectively; P = 0.048). Propensity scores identified 2257 patients per group with similar baseline profiles. In the matched groups, patients who had mini-AVR, despite longer cardiopulmonary bypass (81 ± 32 vs 76 ± 28 min; P = 0.004) and cross-clamp (64 ± 24 vs 59 ± 21 min; P ≤ 0.001) times, had lower 30-day mortality rates (1.2% vs 2.0%; P = 0.036), reduced low cardiac output (0.8% vs 1.4%; P = 0.046) and reduced postoperative length of stay (9 ± 8 vs 10 ± 7 days; P = 0.004). Blood transfusions (36.4% vs 30.8%; P ≤ 0.001) and atrial fibrillation (26.0% vs 21.5%, P ≤ 0.001) were higher in patients who had the mini-AVR. CONCLUSIONS In a large multi-institutional recent cohort, minimal access approach aortic valve replacement is associated with reduced 30-day mortality rates and shorter postoperative lengths of stay compared to standard sternotomy. A prospective randomized trial is needed to overcome the possible biases of a retrospective study.
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Affiliation(s)
- Domenico Paparella
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy.,Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | | | - Giuseppe Santarpino
- Department of Cardiac Surgery, Città di Lecce Hospital, GVM Care & Research, Lecce, Italy.,Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Marco Moscarelli
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.,Department of Cardiac Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Piero Guida
- Maugeri Foundation, Cassano delle Murge, Bari, Italy
| | - Khalil Fattouch
- Department of Cardiac Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Vito Margari
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Luigi Martinelli
- Department of Cardiac Surgery, ICLAS, GVM Care & Research, Rapallo, Italy
| | - Alberto Albertini
- Department of Cardiac Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Giuseppe Speziale
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.,Department of Cardiac Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
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25
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Glauber M, Di Bacco L, Cuenca J, Di Bartolomeo R, Baghai M, Zakova D, Fischlein T, Troise G, Viganò G, Solinas M. Minimally Invasive Aortic Valve Replacement with Sutureless Valves: Results From an International Prospective Registry. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 15:120-130. [DOI: 10.1177/1556984519892585] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To report the early and mid-term results of patients who underwent minimally invasive aortic valve replacement (MI-AVR) with a sutureless prosthesis from an international prospective registry. Methods Between March 2011 and September 2018, among 957 patients included in the prospective observational SURE-AVR (Sorin Universal REgistry on Aortic Valve Replacement) registry, 480 patients underwent MI-AVR with self-expandable Perceval aortic bioprosthesis (LivaNova PLC, London, UK) in 29 international institutions through either minithoracotomy ( n = 266) or ministernotomy ( n = 214). Postoperative, follow-up, and echocardiographic outcomes were analyzed for all patients. Results Patient age was 76.1 ± 7.1 years; 64.4% were female. Median EuroSCORE I was 7.9% (interquartile range [IQR], 4.8 to 10.9). Median cardiopulmonary bypass and cross-clamp times were 81 minutes (IQR 64 to 100) and 51 minutes (IQR 40 to 63). First successful implantation was achieved in 97.9% of cases. Two in-hospital deaths occurred, 1 for noncardiovascular causes and 1 following a disabling stroke. In the early (≤30 days) period, stroke rate was 1.4%. Three early explants were reported: 2 due to nonstructural valve dysfunction (NSVD) and 1 for malpositioning. One mild and 1 moderate paravalvular leak were reported. In 16 patients (3.3%) pacemaker implantation was needed. Mean follow-up was 2.4 years (maximum = 7 years). During follow-up 5 explants were reported, 3 due to endocarditis and 2 due to NSVD. Follow-up stroke rate was 2.5%. Three structural valve deteriorations not requiring reintervention were reported. Five-year survival was 91.45%. Conclusions In this large prospective international registry, MI-AVR with Perceval valve confirmed to be safe, reproducible, and effective in an intermediate-risk population, providing excellent clinical recovery both in early and mid-term follow-up.
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Affiliation(s)
| | | | - Jose Cuenca
- CHUAC - Complexo Hospital Universitario, A Coruña, Coruna, Spain
| | | | | | | | - Theodor Fischlein
- Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
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26
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Krishnan S, Sharma A, Subramani S, Arora L, Mohananey D, Villablanca P, Ramakrishna H. Analysis of Neurologic Complications After Surgical Versus Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2019; 33:3182-3195. [DOI: 10.1053/j.jvca.2018.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 11/11/2022]
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27
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The learning curve of minimally invasive aortic valve replacement for aortic valve stenosis. Gen Thorac Cardiovasc Surg 2019; 68:565-570. [DOI: 10.1007/s11748-019-01234-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/15/2019] [Indexed: 01/19/2023]
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28
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Ueno G, Ohno N. Aortic valve approaches in the era of minimally invasive cardiac surgery. Surg Today 2019; 50:815-820. [PMID: 31342159 DOI: 10.1007/s00595-019-01848-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/21/2019] [Indexed: 12/23/2022]
Abstract
The concept of minimally invasive cardiac surgery has been gradually adopted world-wide since its inception more than 2 decades ago. Recently, catheter intervention has been used in the treatment of structural heart disease. Most notably, minimally invasive transcatheter aortic valve implantation is now an established treatment option for aortic valve stenosis. There are three major approaches for minimally invasive aortic valve surgery: via median sternotomy, via the parasternal approach, and via the thoracotomy approach. All these approaches allow for a small skin incision and/or avoid full sternotomy. Moreover, several advanced variations with additional aortic procedures or totally endoscopic management have been developed. When considering each approach, low invasiveness must be balanced with safety, as surgeons broaden their insight of advanced medicine. Physical invasiveness is largely related to the surgical approach in minimally invasive surgery. We review the history and evolution of the different surgical approaches for minimally invasive aortic valve replacement.
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Affiliation(s)
- Go Ueno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Amagasaki, Hyogo, 660-8550, Japan
| | - Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Amagasaki, Hyogo, 660-8550, Japan.
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29
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Robinson DA, Johnson CA, Goodman AM, Knight PA. Concomitant Annular Enlargement in Minimally Invasive Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:159-167. [PMID: 31039682 DOI: 10.1177/1556984519827685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient-prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy. METHODS Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed. RESULTS Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m2. All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%. CONCLUSIONS Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.
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Affiliation(s)
- Davida A Robinson
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Carl A Johnson
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Ariana M Goodman
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Peter A Knight
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
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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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Right Mini-Thoracotomy Subaortic Membrane Resection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:428-432. [PMID: 30547896 DOI: 10.1097/imi.0000000000000564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Subaortic membrane is an anatomical intracardiac anomaly that may cause discrete subaortic stenosis and aortic insufficiency. Patients requiring subaortic membrane resection may benefit from a minimally invasive approach; however, subaortic membranes are typically resected through a median sternotomy. We present our initial clinical experience of adult patients who have undergone a mini-thoracotomy subaortic membrane resection. METHODS Eight patients who underwent an elective subaortic membrane resection performed through a mini-thoracotomy were retrospectively reviewed. A 5-cm mini-thoracotomy incision was made in the 2nd intercostal space; a videoscope was inserted through a separate incision within the same interspace. Cardiopulmonary bypass (CPB) was instituted via central arterial and peripheral venous cannulation and an aortotomy was made. The subaortic membrane was resected with shafted instruments. The left ventricular outflow tract was inspected and CPB was weaned. Thirty-day mortality, intensive care and hospital length of stay, ventilation time, operative times, postoperative morbidity, and need for additional procedures were evaluated. RESULTS The median CPB and cross-clamp times were 60 and 42 minutes, respectively. The median time to extubation was 3.6 hours. The median intensive care unit and hospital stay were 22 hours and 3 days, respectively. The postoperative left ventricular outflow tract mean gradients decreased significantly (26.5 vs. 9.4 mm Hg, P = 0.001). There were no conversions to sternotomy, perioperative strokes, or 30-day mortality. CONCLUSIONS Subaortic membranes can be resected through a mini-thoracotomy approach with excellent clinical results.
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Chang C, Raza S, Altarabsheh SE, Delozier S, Sharma UM, Zia A, Khan MS, Neudecker M, Markowitz AH, Sabik JF, Deo SV. Minimally Invasive Approaches to Surgical Aortic Valve Replacement: A Meta-Analysis. Ann Thorac Surg 2018; 106:1881-1889. [DOI: 10.1016/j.athoracsur.2018.07.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/18/2018] [Accepted: 07/03/2018] [Indexed: 11/25/2022]
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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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Johnson CA, Melvin AL, Robinson DA, Amirjamshidi H, Knight PA, Gosev I. Titanium Fastener Utilization During HeartMate 3 Left Ventricular Assist Device Implantation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:361-364. [PMID: 30394954 DOI: 10.1097/imi.0000000000000560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the feasibility of using titanium fasteners for securement of the inflow sewing ring during HeartMate 3 implantation. The secondary objective was to compare cardiopulmonary bypass and total operative times between the titanium fastener and hand-tied knot groups. METHODS Clearance between the sewing ring and the HeartMate 3 device was assessed in vitro. Thirty-one patients undergoing HeartMate 3 implantation via median sternotomy at a single center from April 2017 to February 2018 were reviewed. The sewing ring was secured with hand-tied knots (n = 18) or titanium fasteners (n = 13). Cannulation strategy and implantation technique were otherwise identical between groups. Central arterial and venous cannulation was performed for cardiopulmonary bypass. The left ventricular apex was cored, and the sewing ring was attached with hand-tied knots or titanium fasteners. RESULTS There was adequate clearance for the titanium fastener to secure the inflow sewing ring and then connect to the HeartMate 3 in vitro. The inflow sewing ring was successfully secured during HeartMate 3 implantation in the titanium fastener group. Cardiopulmonary bypass time was 75 and 92 minutes for the titanium fastener and hand-tied groups, respectively (P < 0.03). Total operative time was 177 and 193 minutes for the titanium fastener and hand-tied groups, respectively (P = 0.513). CONCLUSIONS The inflow sewing ring of the HeartMate 3 was efficiently secured using titanium fasteners. Titanium fasteners resulted in shorter cardiopulmonary bypass times compared with the hand-tied group. There was no difference in total operative time.
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Affiliation(s)
- Carl A Johnson
- From the Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY USA
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Right Mini-thoracotomy Bentall Procedure. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:328-331. [DOI: 10.1097/imi.0000000000000555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Bentall procedures are traditionally performed through a median sternotomy. The right mini-thoracotomy approach is increasingly used in aortic valve replacement. This approach has been shown to have decreased blood loss and hospital length of stay compared with sternotomy. A right mini-thoracotomy approach may also be beneficial in selected patients requiring aortic root surgery. We present our initial clinical experience of patients who have undergone a right mini-thoracotomy Bentall. Methods This is a single-center retrospective review of seven patients who underwent a primary elective right anterior mini-thoracotomy Bentall. A thoracoscope was used in each case. Automated suturing technology was used for annular suturing in three of the seven patients. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital length of stay, time to extubation, operative times, as well as postoperative sequelae including stroke, infection, and bleeding. Results Median cardiopulmonary bypass, cross-clamp, and circulatory arrest time were 217, 153, and 28 minutes, respectively. Median time to extubation was 10 hours and median intensive care unit and hospital stay was 1 and 4 days, respectively. One patient had a wound infection and one returned to the operating room for bleeding. There were no in-hospital or 30-day mortalities. Conclusions The Bentall procedure can be performed through a right anterior mini-thoracotomy in selected patients with excellent clinical results.
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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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Welp HA, Herlemann I, Martens S, Deschka H. Outcomes of aortic valve replacement via partial upper sternotomy versus conventional aortic valve replacement in obese patients. Interact Cardiovasc Thorac Surg 2018; 27:481-486. [DOI: 10.1093/icvts/ivy083] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 02/22/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Henryk A Welp
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
| | - Isabell Herlemann
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
| | - Sven Martens
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
| | - Heinz Deschka
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
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Tavakoli R, Leprince P, Gassmann M, Jamshidi P, Yamani N, Amour J, Lebreton G. Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement. J Vis Exp 2018. [PMID: 29630054 DOI: 10.3791/57323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.
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Affiliation(s)
- Reza Tavakoli
- Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie; Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich;
| | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie
| | - Max Gassmann
- Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich
| | | | | | - Julien Amour
- Department of Anesthesiology and Intensive Care Unit, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie
| | - Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie
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Johnson CA, Wood KL, Melvin AL, Lebow BF, Knight PA. Video assisted right mini-thoracotomy for aortic root replacement. J Vis Surg 2018; 4:38. [PMID: 29552520 DOI: 10.21037/jovs.2018.01.15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/16/2018] [Indexed: 11/06/2022]
Abstract
Aortic root replacement is typically performed through a median sternotomy. The right anterior mini-thoracotomy approach has been shown to decrease hospital length of stay in aortic valve surgery when compared to sternotomy. This approach is rare in ascending aortic surgery due to technical challenges which include exposure and annular suture placement. Automated suturing technology is now available to facilitate the placement of annular sutures. The use of a camera greatly enhances visualization of the aortic root. A right anterior mini-thoracotomy is performed via a 5 cm incision in the right second intercostal space with a camera port placed lateral to the incision. Peripheral arterial and venous cannulation are performed. The aortic cross clamp is placed through a 5 mm incision in the third interspace anterior to mid axillary line. Histidine tryptophan ketoglutarate (HTK) cardioplegia is administered and deep hypothermic circulatory arrest is achieved followed by completion of the distal anastomosis with a 4-0 polypropylene running suture. After aortic leaflet removal, annular and prosthetic sutures are placed with shafted instruments or with automated suturing technology. Coronary button suturing and graft-to-graft anastomoses are performed with shafted instruments. Aortic root procedures can be performed safely through a right anterior mini-thoracotomy. The use of a camera and automated suturing technology may further facilitate this procedure, enabling more surgeons to offer this less invasive approach to patients.
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Affiliation(s)
- Carl A Johnson
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Katherine L Wood
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Amber L Melvin
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Brandon F Lebow
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter A Knight
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Wong JK, Melvin AL, Siordia JA, Joshi DJ, Sauer JS, Knight PA. Novel Automated Suturing Technology for Minimally Invasive Aortic Valve Replacements. Ann Thorac Surg 2017; 105:645-649. [PMID: 29174775 DOI: 10.1016/j.athoracsur.2017.07.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 07/20/2017] [Accepted: 07/21/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE Annular suture placement during minimally invasive right anterior thoracotomy aortic valve replacements (MI-AVR) can be challenging. We present the early clinical experience with novel automated suturing technology that may reduce the technical difficulty of this operation. DESCRIPTION The technology presented involves an automated articulating suturing device that simultaneously drives dual-curved needles through the aortic annulus to place a pledgeted horizontal mattress suture remotely; a second device with 2 straight needles places suture through the sewing cuff of a prosthetic heart valve. EVALUATION Automated annular suturing was used in five MI-AVR procedures, which were successfully completed, with no paravalvular leaks detected and a mean aortic valve gradient of 6.4 mm Hg postprocedure. Mean aortic cross-clamp and cardiopulmonary bypass times were 100 and 134 minutes, respectively. All 5 patients were successfully discharged home, with a mean intensive care unit and total length of stay of 2 and 7 days, respectively. CONCLUSIONS Automated suturing during MI-AVRs is feasible and may reduce the technical challenge of this operation. Further research is necessary to determine its effect on patient outcomes.
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Affiliation(s)
- Joshua K Wong
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York.
| | - Amber L Melvin
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Juan A Siordia
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Devang J Joshi
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | | | - Peter A Knight
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
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Median sternotomy versus intercostal thoracotomy for lung lobectomy: A comparison of short-term outcome in 134 dogs. Vet Surg 2017; 47:104-113. [DOI: 10.1111/vsu.12741] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 05/15/2017] [Accepted: 06/12/2017] [Indexed: 11/26/2022]
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Bouhout I, Morgant MC, Bouchard D. Minimally Invasive Heart Valve Surgery. Can J Cardiol 2017; 33:1129-1137. [DOI: 10.1016/j.cjca.2017.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/22/2017] [Accepted: 05/22/2017] [Indexed: 11/26/2022] Open
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Zubair MH, Smith JM. Updates in Minimally Invasive Cardiac Surgery for General Surgeons. Surg Clin North Am 2017; 97:889-898. [DOI: 10.1016/j.suc.2017.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Tokoro M, Ito T, Maekawa A, Sawaki S, Yanagisawa J, Ozeki T, Orii M. Trans-right axillary aortic valve replacement: propensity-matched comparison with standard sternotomy approach†. Interact Cardiovasc Thorac Surg 2017; 25:521-525. [DOI: 10.1093/icvts/ivx238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 06/20/2017] [Indexed: 11/14/2022] Open
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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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Bening C, Hamouda K, Oezkur M, Schimmer C, Schade I, Gorski A, Aleksic I, Leyh R. Rapid deployment valve system shortens operative times for aortic valve replacement through right anterior minithoracotomy. J Cardiothorac Surg 2017; 12:27. [PMID: 28511707 PMCID: PMC5434633 DOI: 10.1186/s13019-017-0598-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 05/10/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND There is growing evidence from the literature that right anterior minithoracotomy aortic valve replacement (RAT-AVR) improves clinical outcome. However, increased cross clamp time is the strongest argument for surgeons not performing RAT-AVR. Rapid deployment aortic valve systems have the potential to decrease cross-clamp time and ease this procedure. We assessed clinical outcome of rapid deployment and conventional valves through RAT. METHODS Sixty-eight patients (mean age 76 ± 6 years, 32% females) underwent RAT-AVR between 9/2013 and 7/2015. According to the valve type implanted the patients were divided into two groups. In 43 patients (R-group; mean age 74.1 ± 6.6 years) a rapid deployment valve system (Edwards Intuity, Edwards Lifesciences Corp; Irvine, Calif) and in 25 patients (C-group; mean age 74.2 ± 6.6 years) a conventional stented biological aortic valve was implanted. RESULTS Aortic cross-clamp (42.1 ± 12 min vs. 68.3 ± 20.3 min; p < 0.001) and bypass time (80.4 ± 39.3 min vs. 106.6 ± 23.2 min; p = 0.001) were shorter in the rapid deployment group (R-group). We observed no differences in clinical outcome. Postoperative gradients (R-group: max gradient, 14.3 ± 8 mmHg vs. 15.5 ± 5 mmHg (C-group), mean gradient, 9.2 ± 1.7 mmHg (R-group) vs. 9.1 ± 2.3 mmHg (C-group) revealed no differences. However, larger prostheses were implanted in C-group (25 mm; IQR 23-27 mm vs. 23 mm; IQR 21-25; p = 0.009). CONCLUSIONS Our data suggest that the rapid deployment aortic valve system reduced cross clamp and bypass time in patients undergoing RAT-AVR with similar hemodynamics as with larger size stented prosthesis. However, larger studies and long-term follow-up are mandatory to confirm our findings.
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Affiliation(s)
- Constanze Bening
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Khaled Hamouda
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mehmet Oezkur
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Institute for Clinical and Biometry, University of Wuerzburg, Wuerzburg, Germany
| | - Christoph Schimmer
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ina Schade
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Armin Gorski
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ivan Aleksic
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Rainer Leyh
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
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Doenst T, Essa Y, Jacoub K, Moschovas A, Gonzalez-Lopez D, Kirov H, Diab M, Bargenda S, Faerber G. Cardiac surgery 2016 reviewed. Clin Res Cardiol 2017; 106:851-867. [PMID: 28396989 DOI: 10.1007/s00392-017-1113-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/07/2017] [Indexed: 01/09/2023]
Abstract
For the year 2016, more than 20,000 published references can be found in Pubmed when entering the search term "cardiac surgery". Publications last year have helped to more clearly delineate the fields where classic surgery and modern interventional techniques overlap. The field of coronary bypass surgery (partially compared to percutaneous coronary intervention) was enriched by five large prospective randomized trials. The value of CABG for complex coronary disease was reconfirmed and for less complex main stem lesions, PCI was found potentially equal. For aortic valve treatment, more evidence was presented for the superiority of transcatheter aortic valve implantation for patients with intermediate risk. However, the 2016 evidence argued against the liberal expansion to the low-risk field, where conventional aortic valve replacement still appears superior. For the mitral valve, many publications emphasized the significant impact of mitral valve reconstruction on survival in structural mitral regurgitation. In addition, there were many relevant and other interesting contributions from the purely operative arena in the fields of coronary revascularization, surgical treatment of valve disease, terminal heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While this article attempts to summarize the most pertinent publications it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.
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Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany.
| | - Yasin Essa
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Khalil Jacoub
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Alexandros Moschovas
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - David Gonzalez-Lopez
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Steffen Bargenda
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
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Traditional Sternotomy Versus Minimally Invasive Aortic Valve Replacement in Patients Stratified by Ejection Fraction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:33-40. [PMID: 28099179 DOI: 10.1097/imi.0000000000000338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Low ejection fraction (EF < 40%) portends adverse outcomes in patients undergoing valvular heart surgery. The role of traditional median sternotomy aortic valve replacement (SAVR) compared with minimally invasive aortic valve replacement (MIAVR) in this cohort remains incompletely understood. METHODS A multi-institutional retrospective review of 1503 patients who underwent SAVR (n = 815) and MIAVR via right anterior thoracotomy (n = 688) from 2011 to 2014 was performed. Patients were stratified into two groups: EF of less than 40% and EF of 40% or more. In each EF group, SAVR and MIAVR patients were propensity matched by age, sex, body mass index, race, diabetes, hypertension, dyslipidemia, dialysis, cerebrovascular disease, cardiovascular disease, cerebrovascular accident, peripheral vascular disease, last creatinine level, EF, previous MI and cardiogenic shock, and the Society for Thoracic Surgeons (STS) score. RESULTS Among patients with an EF of 40% or more (377 pairs), patients who underwent MIAVR compared with SAVR had decreased intensive care unit hours (56.8% vs 84.6%, P < 0.001), postoperative length of stay (7.1 vs 7.9 days, P = 0.04), incidence of atrial fibrillation (18.8% vs 38.7%, P < 0.001), bleeding (0.8% vs 3.2%, P = 0.04), and a trend toward decreased 30-day mortality (0.3% vs 1.3%, P = 0.22). The STS scores were largely equivalent in patients undergoing MIAVR compared with SAVR (2.4% vs 2.6%, P = 0.09). In patients with an EF of less than 40% (35 pairs), there was no difference in intensive care unit hours (69% vs 72.6%, P = 0.80), postoperative length of stay (10.3 vs 7.2 days, P = 0.13), 30-day mortality (3.8% vs 0.8%, P = 0.50), or the STS score (3.3% vs 3.2%, P = 0.68). CONCLUSIONS Minimally invasive aortic valve replacement in patients with preserved EF was associated with improved short-term outcomes compared with SAVR. In patients with left ventricular dysfunction, short-term outcomes between MIAVR and SAVR are largely equivalent.
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Nguyen TC, Thourani VH, Pham JQ, Zhao Y, Terwelp MD, Balan P, Ocazionez D, Loghin C, Smalling RW, Estrera AL, Lamelas J. Traditional Sternotomy versus Minimally Invasive Aortic Valve Replacement in Patients Stratified by Ejection Fraction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Tom C. Nguyen
- Department of Cardiothoracic Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Vinod H. Thourani
- Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Justin Q. Pham
- Department of Cardiothoracic Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Yelin Zhao
- Division of Cardiology, Department of Internal Medicine, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Matthew D. Terwelp
- Department of Cardiothoracic Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Prakash Balan
- Division of Cardiology, Department of Internal Medicine, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Daniel Ocazionez
- Department Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Memorial Hermann Hospital, Houston, TX USA
| | - Catalin Loghin
- Division of Cardiology, Department of Internal Medicine, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Richard W. Smalling
- Division of Cardiology, Department of Internal Medicine, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Anthony L. Estrera
- Department of Cardiothoracic Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA
| | - Joseph Lamelas
- Department of Cardiac Surgery, Mount Sinai Medical Center, Miami Beach, FL USA
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Moore M, Barnhart GR, Chitwood WR, Rizzo JA, Gunnarsson C, Palli SR, Grossi EA. The economic value of INTUITY in aortic valve replacement. J Med Econ 2016; 19:1011-7. [PMID: 27549435 DOI: 10.1080/13696998.2016.1220949] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The recent development of the EDWARDS INTUITY Elite™ (EIE) valve system enables the rapid deployment of a prosthetic surgical heart valve in an aortic valve replacement (AVR) procedure via both the minimally invasive (MISAVR) and conventional (CAVR) approaches. In order to understand its economic value, this study performed a cost evaluation of the EIE valve system used in a MIS rapid-deployment approach (MIS-RDAVR) vs MISAVR and CAVR, respectively, compared to standard prosthetic aortic valves. METHODS A simulation model was developed using TreeAge (and validated with MS Excel) to compare the inpatient utilization and complication costs for each treatment arm. Thirty-day clinical end-points for the MIS-RDAVR (mortality and complications) were taken from the TRANSFORM trial; and a best evidence review of the published literature was used for the MISAVR and CAVR approaches. Studies were pooled and parameter estimates were weighted by sample size in order to compare the TRANSFORM patients. Cost data (2016 USD) were taken from the Premier database. Incremental cost and cost-effectiveness was assessed and one-way/probabilistic sensitivity analyses performed to gauge the robustness of the results. RESULTS MIS-RDAVR costs $2,621 less than CAVR and had lower mortality rates, making it a superior (dominant) technology relative to CAVR. MIS-RDAVR costs $4,560 more than MISAVR, but was associated with an additional 0.20 life years-per-patient. This implies a cost-effectiveness ratio of $22,903 per-life-year-gained. Thus, MIS-RDAVR is cost-effective compared to MISAVR. CONCLUSIONS The EIE valve system deployed in a MIS approach appears to be a cost-effective technology compared to MISAVR and CAVR. When compared to CAVR it may achieve cost savings as well. These results suggest that MIS-RDAVR confers superior economic value compared to both standard MISAVR and CAVR via lowered key complication rates (re-operation, renal complications, wound infection, TIA, endocarditis) and utilization (cross-clamp time, hospital ward days).
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Affiliation(s)
| | | | | | - John A Rizzo
- d Stony Brook University , Stony Brook , NY , USA
| | - Candace Gunnarsson
- e CTI Clinical Trial and Consulting Services, Inc. , Cincinnati , OH , USA
| | - Swetha R Palli
- e CTI Clinical Trial and Consulting Services, Inc. , Cincinnati , OH , USA
| | - Eugene A Grossi
- f New York University School of Medicine , New York , NY , USA
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