A matched pairs analysis of non-rib-spreading, fully endoscopic, mini-incision technique versus conventional mini-thoracotomy for mitral valve repair

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Mitral Valve Surgery-A Propensity Matched Competitive Analysis

Background and Objectives: Transaxillary access is a straightforward “single incision—direct vision” concept, based on a 5 cm skin incision in the right anterior axillary line. It is suitable for aortic, mitral and tricuspid surgery. The present study evaluates the hospital outcomes of the transaxillary access for isolated mitral valve surgery compared with full sternotomy. Patients and Methods: The final study group included 480 patients. A total of 160 consecutive transaxillary patients served as treatment group (MICS-MITRAL). Based on a multivariate logistic regression model including age, sex, body-mass-index, EuroScore II and LVEF, a 1:2 propensity matched control-group (n = 320) was generated out of 980 consecutive sternotomy patients. Redo surgeries, endocarditis or combined procedures were excluded. The mean age was 66.6 ± 10.6 years, 48.6% (n = 234) were female. EuroSCORE II averaged 1.98 ± 1.4%. Results: MICS-MITRAL had longer perfusion (88.7 ± 26.6 min vs. 68.7 ± 32.7 min; p < 0.01) and cross-clamp (64.4 ± 22.3 min vs. 49.7 ± 22.4 min; p < 0.01) times. This did not translate into longer procedure times (132 ± 31 min vs. 131 ± 46 min; p = 0.76). Both groups showed low rates of failed repair (MICS-MITRAL: n = 6/160; 3.75%; Sternotomy: n = 10/320; 3.1%; p = 0.31). MICS-MITRAL had lower transfusion rates (p ≤ 0.001), less re-exploration for bleeding (p = 0.04), shorter ventilation times (p = 0.02), shorter ICU-stay (p = 0.05), less postoperative hemofiltration (p < 0.01) compared to sternotomy patients. No difference was seen in the incidence of stroke (p = 0.47) and postoperative delirium (p = 0.89). Hospital mortality was significantly lower in MICS-MITRAL patients (0.0% vs. 3.4%; p = 0.02). Conclusions: The transaxillary access for MICS-MITRAL provides superior cosmetics and excellent clinical outcomes. It can be performed at least as safely and in the same time frame as conventional mitral surgery by sternotomy.

Antegrade axillary arterial perfusion in 3D endoscopic minimally-invasive mitral valve surgery

Background

Minimally-invasive (MIS) mitral valve (MV) surgery has become standard therapy in many cardiac surgery centers. While femoral arterial perfusion is the preferred cannulation strategy in MIS mitral valve surgery, retrograde arterial perfusion is known to be associated with an increased risk for cerebral atheroembolism, particularly in atherosclerosis patients. Therefore, antegrade perfusion may be beneficial in such cases. This analysis aimed to compare outcomes of antegrade axillary vs. retrograde femoral perfusion in the MIS mitral valve surgery.

Methods

This analysis includes 50 consecutive patients who underwent MIS between 2016 and 2020 using arterial cannulation of right axillary artery (Group A) due to severe aortic arteriosclerosis. Perioperative outcomes of the study group were compared with a historical control group of retrograde femoral perfusion (Group F) which was adjusted for age and gender (n = 50). Primary endpoint of the study was in-hospital mortality and perioperative cerebrovascular events.

Results

Patients in group A had a significantly higher perioperative risk as compared to Group F (EuroSCORE II: 3.9 ± 2.5 vs. 1.6 ± 1.5; p = 0.001; STS-Score: 2.1 ± 1.4 vs. 1.3 ± 0.6; p = 0.023). Cardiopulmonary bypass time (group A: 172 ± 46; group F: 178 ± 51 min; p = 0.627) and duration of surgery (group A: 260 ± 65; group F: 257 ± 69 min; p = 0.870) were similar. However, aortic cross clamp time was significantly shorter in group A as compared to group F (86 ± 20 vs. 111 ± 29 min, p < 0.001). There was no perioperative stroke in either groups. In-hospital mortality was similar in both groups (group A: 1 patient; group F: 0 patients; p = 0.289). In group A, one patient required central aortic repair due to intraoperative aortic dissection. No further cardiovascular events occurred in Group A patients.

Conclusion

Selective use of antegrade axillary artery perfusion in patients with systemic atherosclerosis shows similar in-hospital outcomes as compared to lower risk patients undergoing retrograde femoral perfusion. Patients with higher perioperative risk and severe atherosclerosis can be safely treated via the minimally invasive approach with antegrade axillary perfusion.

Technical tips in non-robotic endoscopic mitral valve surgery: How to approach and expose the mitral valve

The non-robotic endoscopic mitral valve surgery is performed via a right mini-thoracotomy without the use of rib spreader or robotic assistance. Although it has several advantages over the direct vision minimally invasive and robotic approaches, operating in very limited working space without robotic assistance is technically demanding. In the first place, it is impossible to perform non-robotic endoscopic mitral valve surgery safely and efficiently without knowing how to approach and expose the mitral valve in very limited working space without robotic assistance. This manuscript introduces detailed technical tips for efficient approach and uncompromised exposure of the mitral valve in non-robotic endoscopic mitral valve surgery, including separate bicaval cannulation, decentralized positioning of the instruments, controlling the direction of traction sutures and appropriate use of retractors.

Comparative efficacy of five surgical methods in the treatment of mitral regurgitation: A systematic review and network meta-analysis

OBJECTIVE

This study has been compared the effectiveness of different surgical methods in the treatment of mitral regurgitation (MR) in adults by using the network meta-analysis method, so as to provide reference for clinical selection of the best surgical scheme.

METHODS

The PubMed, EMBASE, the Cochrane Library, CNKI, and Chongqing VIP Information databases were comprehensively searched until December 2020. We collected retrospective comparative studies on surgical procedures including 3D endoscopic mitral valve surgery (3D-MVS), robot-assisted mitral valve surgery (R-MVS); totally thoracoscopic mitral valve surgery (T-MVS), small incision mitral valve surgery (M-MVS), and traditional thoracotomy mitral valve surgery (C-MVS). Stata16.0 and Addis1.16.8 software was used for network meta-analysis using the Bayesian approach.

RESULTS

A total of 31 studies were included, 12,998 patients, involving five surgical methods. Network meta-analysis showed that: in terms of complications (odds ratio [OR]: 0.65, 95% CI: 0.13-3.00, probability rank = 0.37) and MR (OR: 0.03, 95% CI: 0.0-8315, probability rank = 0.64), the 3D-MVS group had the lowest event rate. In terms of blood transfusion rate (OR: 0.55, 95% CI: 0.16-1.84, probability rank = 0.45), T-MVS had the lowest event rate. In addition, with the exception of operation time and chest drainage, the R-MVS group has the best curative effect.

CONCLUSION

This minimally invasive surgery has their own advantages and disadvantages. Overall, 3D-MVS is most satisfactory, but more samples are needed.

A Novel Plug-Based Vascular Closure Device for Percutaneous Femoral Artery Closure in Patients Undergoing Minimally-Invasive Valve Surgery

Objectives: Surgical exposure of groin vessels to establish cardiopulmonary bypass (CPB) for minimally-invasive valve surgery (MIS) is standard of care but may result in postoperative wound healing disorders or seroma formation. Therefore, adaption of transcatheter techniques for fully percutaneous insertion of CPB cannulae may improve clinical results. We herein analyze a single center experience with a novel plug-based vascular closure device for MIS.

Methods: Between 03/2020 and 02/2021 MIS using the MANTA™ (Teleflex Medical Inc., Wayne, PA, USA) vascular closure device was performed in 28 consecutive patients (58.8 ± 10.6 years, 60.3% male, logEuroSCORE II 1.1 ± 0.8%) receiving mitral and/or tricuspid valve repair/replacement. Concomitant procedures were left atrial appendage occlusion and cryoablation for atrial fibrillation in 21.4% (6/28) and 10.7% (3/28) of patients, respectively. Data were retrospectively analyzed in accordance with standardized M-VARC definitions. MANTA™ device success and early safety was defined as absence of any access site or access related vascular injury and major and life-threatening bleeding complications.

Results: MANTA™ device success with immediate hemostasis and early safety were 96.4% (27/28). In one case, device failure necessitated surgical cut down without further complications. Mean aortic cross clamp time and cardiopulmonary bypass were 96.5 ± 24.2 min and 150.2 ± 33.6 min. Stroke, renal failure or myocardial infarction were not observed. Intensive care unit and total hospital stay were 1.7 ± 0.8 days and 10.1 ± 5.7 days. Overall 30-day mortality was 0%. Post-procedure echocardiography presented one case of residual moderate tricuspid regurgitation and competent valves in all other cases.

Conclusions: The MANTA™ device is safe and effective in MIS. Its ease of use and effectiveness to achieve immediate hemostasis have further simplified MIS.

Minimally Invasive Mitral Surgery: Patient Selection and Technique

In most patients, minimally invasive approaches to mitral valve surgery are technically possible. However, in practice, patient selection is critical to mitigate safety concerns when performing the procedure. In this article, we describe our approach to preoperative assessment for minimally invasive mitral valve surgery candidacy, as well as discussing the technical aspects of procedure execution.

Comparison of postoperative outcomes between robotic mitral valve replacement and conventional mitral valve replacement

BACKGROUND

Robotic mitral valve surgery continues to become widespread all over the world in direct proportion to the developing technology. In this study, we aimed to compare the postoperative results of robotic mitral valve replacement and conventional mitral valve replacement.

METHODS

A total of consecutive 130 patients who underwent robotic mitral valve replacement and conventional mitral valve replacement with full sternotomy between 2014 and 2020 were included in our study. All patients were divided into two groups: Group I, with 64 patients who underwent robotic mitral valve replacement and Group II, with 66 patients with conventional full sternotomy. General demographic data (age, gender, body weights, etc.), comorbidities (hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral artery disease, hyperlipidemia, etc.), intraoperative variables (cardiopulmonary bypass times, and cross-clamp times), postoperative ventilation times, drainage amounts, transfusion amount, inotropic need, revision, arrhythmia, intensive care and hospital stay times, and mortality were analyzed retrospectively.

RESULTS

There was no significant difference between demographic data, such as age, gender, body kit index, and preoperative comorbid factors of both patient groups (p > .05). Cardiopulmonary bypass time (204.12 ± 45.8 min) in Group I was significantly higher than Group II (98.23 ± 17.8 min) (p < .001). Cross-clamp time in Group I (143 ± 27.4 min) was significantly higher than Group II (69 ± 15.2 min) (p < .001). Drainage amount in Group I (290 ± 129 cc) was significantly lower than Group II (561 ± 136 cc) (p < .001). The erythrocyte suspension transfusion requirement was 0.4 ± 0.3 units in Group I; it was 0.9 ± 1.2 units in Group II, and this requirement was found to be significantly lower in Group I (p = .014). While the mean mechanical ventilation time was 5.3 ± 3.9 h in Group I, it was 9.6 ± 4.2 h in Group II. It was significantly lower in Group I (p = .001). Accordingly, intensive care stay (p = .006) and hospital stay (p = .003) were significantly lower in Group I. In the early postoperative period, three patients in Group I and four patients in Group II were revised due to bleeding. In the postoperative hospitalization period, neurological complications were observed in one patient in Group I and two patients in Group II. Two patients in Group I returned to the sternotomy due to surgical difficulties. Two patients died in both groups postoperatively, and there was no significant difference in mortality (p = .97).

CONCLUSION

According to conventional methods, robotic mitral valve replacement is an effective and reliable method since total perfusion and cross-clamp times are longer, drainage amount and blood transfusion need are less, and ventilation time, intensive care, and hospital stay time are shorter.

Surgical effect and long-term clinical outcomes of robotic mitral valve replacement: 10-year follow-up study

BACKGROUND

To assess the safety and effectiveness, clinical experience with totally robotic mitral valve replacement (TE-MVR) for treating valvular heart disease was summarized and analyzed, and patients' recovery conditions were followed-up.

METHODS

The clinical data of 47 patients who received TE-MVR in our hospital between October 2008 and December 2015 were retrospectively analyzed. Among the patients, there are 26 men and 21 women. The mean age was 47.53±10.80 years. We followed up the transesophageal echocardiography (TTE) data of post-discharge patients and analyzed the operation results to determine the surgical effects of TE-MVR. The surgeries were mainly performed with the da Vinci Si robotic surgical system.

RESULTS

Thirty-five mechanical valves and twelve bioprosthetic valves were implanted. The cardiopulmonary bypass and aortic cross-clamping times were 122.02±25.45 min and 85.68±20.70 min, respectively. There was no operative mortality. The perioperative complication could only be found in one case, which was pleural effusion. All the TTE results were satisfying before discharge. No paravalvular leakage or prosthetic valve dysfunction was detected. All 47 patients were discharged successfully. During the long-term follow-up (28-110 months), 42 patients were followed-up (89.4%). Most of their heart function was NYHA class I and II. The postoperative TTE showed that the left atrial diameter and left ventricle diameter were decreased (P<0.01).

CONCLUSIONS

TE-MVR is reliable and effective, and the postoperative follow-up results revealed good heart function. Patients will obtain benefits from TE-MVR, such as small trauma and rapid recovery. Thus, it is a good minimally-invasive surgery of choice.

[Comparison of quality of life and long-term outcomes following mitral valve replacement through robotically assisted versus median sternotomy approach]

OBJECTIVE

To compare the mid- and long-term outcomes of patients receiving mitral valve replacement through robotically assisted and conventional median sternotomy approach.

METHODS

The data of 47 patients who underwent da Vinci robotic mitral valve replacement in our hospital between January, 2007 and December, 2015 were collected retrospectively (robotic group). From a total of 286 patients undergoing mitral valve replacement through the median thoracotomy approach between March, 2002 and June, 2014, 47 patients were selected as the median sternotomy group for matching with the robotic group at a 1:1 ratio. The perioperative data and follow-up data of the patients were collected, and the quality of life (QOL) of the patients at 30 days and 6 months was evaluated using the Quality of Life Short Form Survey (SF-12). The time of returning to work postoperatively and the patients' satisfaction with the surgical incision were compared between the two groups.

RESULTS

All the patients in both groups completed mitral valve replacement successfully, and no death occurred during the operation. In the robotic group, only one patient experienced postoperative complication (pleural effusion); in median sternotomy group, one patient received a secondary thoracotomy for management of bleeding resulting from excessive postoperative drainage, and one patient died of septic shock after the operation. The volume of postoperative drainage, postoperative monitoring time, ventilation time, and postoperative hospital stay were significantly smaller or shorter in the robotic group than in the thoracotomy group (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups. Assessment of the patients at 30 days after the operation showed a better quality of life in the robotic group, but the difference between the two groups tended to diminish at 6 months. The patients in the robotic group reported significantly better satisfaction with the incision than those in the thoracotomy group (P < 0.001). At 6 months after the operation, the patients in the robotic group showed significantly faster recovery of work and daily activities than those in the thoracotomy group.

CONCLUSIONS

Robotically assisted mitral valve replacement is safe and reliable. Compared with the median sternotomy approach, the robotic approach is less invasive and promotes faster postoperative recovery of the patients, who have better satisfaction with the quality of life and wound recovery.

Minimally invasive mitral valve repair for functional mitral regurgitation

Systolic heart failure is frequently accompanied by a relevant functional mitral valve regurgitation (FMR) which develops as a direct sequela of the ongoing left ventricular remodelling. The severity of mitral regurgitation is further aggravated by progressive left ventricular enlargement causing leaflet tethering and reduced systolic leaflet movement. The prognosis of such patients is obviously limited by an underlying left ventricular disease, and the correction of secondary FMR has been previously suggested as predominantly ‘cosmetic’ surgery in the setting of ongoing cardiomyopathy. Inferior results of an isolated annuloplasty in type IIIb FMR supported the philosophy of malignant course of progressive cardiomyopathy and resulted in increasingly restricted indications for mitral valve surgery for FMR in the guidelines. The lack of a standardized pathophysiological approach to correct type IIIb FMR led to the development of valve replacement strategy and edge-to-edge catheter-based mitral valve procedures, which became the most frequent procedures in the FMR setting in Europe. Modern mitral valve surgery combines the advantages of 3-dimensional endoscopic minimally invasive surgical approach with standardized subannular repair to address the pathophysiological background of type IIIb FMR. The perioperative results have been significantly improved, and there is a growing evidence of improved long-term stability of subannular repair procedures as compared to isolated annuloplasty. This review article aims to present the current state-of-the-art of the modern mitral valve surgery in FMR and provides suggestions for future trials analysing the potential advantages in these patients.

Early clinical outcomes of thoracoscopic mitral valvuloplasty: a clinical experience of 100 consecutive cases

Background

We reported our experience of 100 consecutive cases of thoracoscopic mitral valvuloplasty in the early period.

Methods

Between September 2017 and December 2019, 100 consecutive cases (aged 49.2±14.7 years; 56% male) of thoracoscopic mitral valvuloplasty had been completed in our institution. The safety and feasibility of this technique was evaluated by its early clinical outcomes.

Results

Mitral valve (MV) repair was performed by means of Carpentier techniques, including leaflet folding in 5 cases, cleft suture in 10, commissuroplasty in 15 including 2 commissurotomy, edge to edge in 1, artificial chordae implantation in 76 cases with an average of 2.5±1.6 (1 to 4) pairs, and prosthetic annuloplasty in all cases. Intraoperative transoesophageal echocardiography (TEE) revealed no mitral regurgitation (MR) in 95 cases and a mild in 2 cases with all coaptation length more than 5 mm. The rest 3 cases with moderate or more MR were successfully reconstructed during a second pump-run. The average cardiopulmonary bypass (CPB) time was 164.4±51.0 min and aortic clamping time was 119.7±39.1 min, and the latest 10 cases were 140.2±45.3 and 96.3±25.4 min, respectively (P<0.05). There was only one operative death from avulsion of left atrial suture after operation and 2 intraoperative re-exploration through a conversion to sternotomy for bleeding. Severe MR was observed in 2 patients 3 months after operation, and MV replacement (MVR) was performed through median sternotomy.

Conclusions

Totally thoracoscopic mitral valvuloplasty was technically feasible, safe, effective, and reproducible in clinical practice after crossing the learning curve.

Totally endoscopic mitral valve repair using a three-dimensional endoscope system: initial clinical experience in Korea

Background

The lack of depth perception is a significant challenge in two-dimensional (2D) video-assisted/directed minimally invasive cardiac surgery (MICS). Accordingly, restoration of stereoscopic vision is potentially beneficial, and we present a single center experience of a three-dimensional (3D) endoscope system in cardiac surgery without robotic assistance.

Methods

We retrospectively reviewed the initial 40 consecutive patients who received totally endoscopic mitral valve (MV) repair using a 3D endoscope system between September 2017 and April 2019. The preoperative characteristics, operative data, and immediate postoperative outcomes, including echocardiographic results, were investigated.

Results

In all the patients (n=40, 100%), successful MV repair using the standard repair techniques was achieved regardless of the location of the MV lesion as follows: anterior leaflet (n=8, 20.0%), posterior leaflet (n=15, 37.5%), and both leaflets (n=17, 42.5%). Concomitant tricuspid ring annuloplasty (n=9, 22.5%) and atrial fibrillation ablation (n=7, 17.5%) were performed. There was no mortality. One reoperation for bleeding occurred. One patient had a sternotomy conversion due to aortic dissection immediately after declamping. Postoperative mitral regurgitation (MR) grades were none or trace in 38 patients (95.0%) and mild in 2 patients (5.0%) on predischarge echocardiography.

Conclusions

Totally endoscopic MV repair using a 3D endoscope system is technically feasible and safe on the basis of this initial experience.

Robotic mitral valve replacements with bioprosthetic valves in 52 patients: experience from a tertiary referral hospital

OBJECTIVES

Robotic mitral valve replacement (MVR) emerged in the late 1990s as an alternative approach to conventional sternotomy. With the increased use of bioprosthetic valves worldwide and strong patient desire for minimally invasive procedures, the safety and feasibility of robotic MVRs with bioprosthetic valves require investigation.

METHODS

Between January 2013 and May 2017, 52 consecutive patients underwent robotic MVRs using the da Vinci Si surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Their mean age was 55.1 ± 13.8 years, and mean EuroSCORE II was 2.25% ± 1.25%. Among the enrolled patients, 32 (61.5%) patients presented with preoperative atrial fibrillation, 6 (11.5%) patients had experienced embolic stroke and 5 (9.6%) patients had undergone previous cardiac surgery. The operations were performed using cardiopulmonary bypass (CPB) under an arrested heart status.

RESULTS

Five porcine valves and 47 bovine valves were implanted. A total of 38 (73.1%) patients received concomitant cardiac procedures, including 26 Cox-maze IV procedures, 12 tricuspid valve repairs and 5 atrial septal defect repairs. The mean aortic cross-clamp and CPB times were 141.3 ± 34.3 min and 217.1 ± 42.0 min, respectively. There was no operative mortality. During the mean follow-up of 29 ± 15 months, no prosthesis degeneration was noted. The average left atrial dimension exhibited a significant decrease from 51.4 ± 11.5 mm to 42.6 ± 10.1 mm.

CONCLUSIONS

Robotic MVR with bioprosthetic valves is safe, feasible and reproducible. Mid-term results are encouraging. Both aortic cross-clamp and CPB times can be improved with experience.

Minimally Invasive Mitral Valve Annuloplasty With Realignment of Both Papillary Muscles for Correction of Type IIIb Functional Mitral Regurgitation

OBJECTIVE

Pathophysiological background of type IIIb functional mitral regurgitation (FMR) is a progressively increasing distance between papillary muscle tips and mitral annular plane. Standard surgical treatment of such FMR by means of undersized mitral annuloplasty is associated with a high recurrence rate.

METHODS

We propose a modified subannular maneuver to correct type IIIb FMR while combining undersized annuloplasty with a controlled realignment of both papillary muscles, thereby fixing the distance between mitral annular plane and papillary muscle tips. The differences of this subannular maneuver as compared with the previously published techniques are the following: (1) controlled realignment of both papillary muscles, (2) fixation of the papillary muscles to mitral annulus distance on an annuloplasty ring, and (3) application in a three-dimensional endoscopic minithoracotomy setting.

RESULTS

We describe a surgical technique of minimally invasive mitral valve repair performed due to severe type IIIb FMR, which includes a modified subannular maneuver to realign both papillary muscles. Preliminary results of the first 10 patients who underwent this procedure at our institution are presented. There was no in-hospital mortality and follow-up echocardiography (mean ± SD echocardiographic follow-up = 10 ± 6 months) demonstrated stable functional results.

CONCLUSIONS

Our initial experience indicates that adding of this subannular maneuver to the standard annuloplasty and thereby fixing the distance between papillary muscles and mitral annular plane have a potential to improve results of surgical FMR treatment.