1
|
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.
Collapse
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
| |
Collapse
|
2
|
Bartakke AA, Carmona-Garcia P, Fuster-Gonzalez M, Reparaz-Vives X. Manejo anestésico en la cirugía de reparación valvular mitral. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
3
|
VAN Kampen A, Kofler M, Meyer A, Gerber M, Sündermann SH, VAN Praet KM, Akansel S, Hommel M, Falk V, Kempfert J. Aortic valve replacement via right anterolateral minithoracotomy: preventing adverse events during the initial learning curve. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:85-90. [PMID: 34825793 DOI: 10.23736/s0021-9509.21.11981-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Despite excellent outcomes and reduced invasiveness, the right anterolateral thoracotomy approach for aortic valve replacement (RALT-AVR) has not been broadly adopted. This study provides results regarding the initial experience and learning curve of a single surgeon performing this procedure. METHODS Periprocedural details and postoperative outcomes of the first 100 consecutive patients who underwent RALT-AVR at our institution were retrospectively analyzed. We conducted a cumulative sum analysis of surgical failure, defined as occurrence of 30-day-mortality, surgical revision for bleeding, conversion to sternotomy, 3rd degree heart block, paravalvular leakage, postoperative stroke or mean transvalvular gradient >20 mmHg. RESULTS The cohort was of low surgical risk (mean EuroSCORE II 1.31%±0.85, mean STS PROM 1.45%±0.97), 58% were males. Median cross-clamp time was 67.5 (57.8-76) min, median CPB time 105 (91.8-119) min, and median operation time 164.5 (144.5-183.2) min. There were no conversions to full sternotomy, 4 cases of revision for bleeding and 2 pacemaker implantations for 3rd degree heart block. Prosthesis function was good (median ΔPmean 10.9 [7.4-13.6] mmHg). Thirty-day-mortality was 0%. The log-likelihood graph never crossed the upper boundary, and after a steady decrease, crossed the lower boundary at 93 patients. CONCLUSIONS RALT-AVR can be performed with acceptable procedural times and satisfactory outcomes. For a well-trained surgeon, adapting to this new procedure does not expose patients to an increased risk, when patient selection and procedural planning are applied appropriately. Cumulative sum failure analysis is an appropriate tool to monitor the transition from standard AVR to the technically more demanding RALT-AVR.
Collapse
Affiliation(s)
- 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 -
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany -
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center 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
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Maria Gerber
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Simon H Sündermann
- 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 Cardiovascular Surgery, Charité University Hospital, Berlin, Germany
| | - 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
| | - Serdar Akansel
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Matthias Hommel
- Department of Anesthesiology, German Heart Center 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 Cardiovascular Surgery, Charité University Hospital, Berlin, Germany
- Department of Health Sciences and Technology, Translational Cardiovascular Technologies, Institute of Translational Medicine, Swiss Federal Institute of Technology (ETH), Zurich, 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
- Department of Cardiovascular Surgery, Charité University Hospital, Berlin, Germany
| |
Collapse
|
4
|
Zientara A, Pepper J, Quarto C. Who took away my aortic valve? Eur J Cardiothorac Surg 2021; 61:187-188. [PMID: 34542593 DOI: 10.1093/ejcts/ezab405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alicja Zientara
- Department of Cardiac Surgery, Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - John Pepper
- Department of Cardiac Surgery, Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Cesare Quarto
- Department of Cardiac Surgery, Royal Brompton Hospital, Guys and St. Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
5
|
Cocchieri R, van de Wetering B, Stijnen M, Riezebos R, de Mol B. The Impact of Biomedical Engineering on the Development of Minimally Invasive Cardio-Thoracic Surgery. J Clin Med 2021; 10:jcm10173877. [PMID: 34501325 PMCID: PMC8432110 DOI: 10.3390/jcm10173877] [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] [Received: 07/13/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022] Open
Abstract
(1) We describe the boundary conditions for minimally invasive cardiac surgery (MICS) with the aim to reduce procedure-related patient injury and discomfort. (2) The analysis of the MICS work process and its demand for improved tools and devices is followed by a description of the relevant sub-specialties of bio-medical engineering: electronics, biomechanics, and materials sciences. (3) Innovations can represent a desired adaptation of an existing work process or a radical redesign of procedure and devices such as in transcutaneous procedures. Focused interaction between engineers, industry, and surgeons is always mandatory (i.e., a therapeutic alliance for addressing 'unmet patient or professional needs'. (4) Novel techniques in MICS lean heavily on usability and safe and effective use in dedicated hands. Therefore, the use of training and simulation models should enable skills selection, a safe learning curve, and maintenance of proficiency. (5) The critical technical steps and cost-benefit trade-offs during the journey from invention to application will be explained. Business considerations such as time-to-market and returns on investment do shape the cost-benefit room for commercial use of technology. Proof of clinical safety and effectiveness by physicians remains important, but establishing the technical reliability of MICS tools and warranting appropriate surgical skills come first.
Collapse
Affiliation(s)
- Riccardo Cocchieri
- Heart Center, OLVG Hospital, 1091 AC Amsterdam, The Netherlands; (R.C.); (R.R.)
| | - Bertus van de Wetering
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands;
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Correspondence: (B.v.d.W.); (B.d.M.)
| | - Marco Stijnen
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands;
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
| | - Robert Riezebos
- Heart Center, OLVG Hospital, 1091 AC Amsterdam, The Netherlands; (R.C.); (R.R.)
| | - Bastian de Mol
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands;
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
- Correspondence: (B.v.d.W.); (B.d.M.)
| |
Collapse
|
6
|
Cerqueira RJ, Heuts S, Gollmann-Tepeköylü C, Syrjälä SO, Keijzers M, Zientara A, Jarral OA, Jacob KA, Haunschild J, Ariyaratnam P, Durko AP, Muller P, Myers PO, Sadaba JR, Lehtinen ML. Challenges and satisfaction in Cardiothoracic Surgery Residency Programmes: insights from a Europe-wide survey. Interact Cardiovasc Thorac Surg 2021; 32:167-173. [PMID: 33236099 DOI: 10.1093/icvts/ivaa248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/03/2020] [Accepted: 09/27/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The increasing complexity of surgical patients and working time constraints represent challenges for training. In this study, the European Association for Cardio-Thoracic Surgery Residents' Committee aimed to evaluate satisfaction with current training programmes across Europe. METHODS We conducted an online survey between October 2018 and April 2019, completed by a total of 219 participants from 24 countries. RESULTS The average respondent was in the fourth or fifth year of training, mostly on a cardiac surgery pathway. Most trainees follow a 5-6-year programme, with a compulsory final certification exam, but no regular skills evaluation. Only a minority are expected to take the examination by the European Board of Cardiothoracic Surgery. Participants work on average 61.0 ± 13.1 h per week, including 27.1 ± 20.2 on-call. In total, only 19.7% confirmed the implementation of the European Working Time Directive, with 42.0% being unaware that European regulations existed. Having designated time for research was reported by 13.0%, despite 47.0% having a postgraduate degree. On average, respondents rated their satisfaction 7.9 out of 10, although 56.2% of participants were not satisfied with their training opportunities. We found an association between trainee satisfaction and regular skills evaluation, first operator experience and protected research time. CONCLUSIONS On average, residents are satisfied with their training, despite significant disparities in the quality and structure of cardiothoracic surgery training across Europe. Areas for potential improvement include increasing structured feedback, research time integration and better working hours compliance. The development of European guidelines on training standards may support this.
Collapse
Affiliation(s)
- Rui J Cerqueira
- Cardiovascular Research and Development Unit, University of Porto and Department of Cardiothoracic Surgery, University Hospital Center of São João, Porto, Portugal
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Simo O Syrjälä
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Marlies Keijzers
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Alicja Zientara
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Omar A Jarral
- Department of Cardiothoracic Surgery, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Andras P Durko
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Patrick Muller
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Patrick O Myers
- Department of Cardiac Surgery, CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | - Miia L Lehtinen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
7
|
Vohra HA, Salmasi MY, Chien L, Baghai M, Deshpande R, Akowuah E, Ahmed I, Tolan M, Bahrami T, Hunter S, Zacharias J. BISMICS consensus statement: implementing a safe minimally invasive mitral programme in the UK healthcare setting. Open Heart 2020; 7:openhrt-2020-001259. [PMID: 33020254 PMCID: PMC7537434 DOI: 10.1136/openhrt-2020-001259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/26/2020] [Accepted: 08/25/2020] [Indexed: 02/03/2023] Open
Abstract
Disseminating the practice of minimally invasive mitral surgery (mini-MVS) can be challenging, despite its original case reports a few decades ago. The penetration of this technology into clinical practice has been limited to centres of excellence, and mitral surgery in most general cardiothoracic centres remains to be conducted via sternotomy access as a first line. The process for the uptake of mini-MVS requires clearer guidance and standardisation for the processes involved in its implementation. In this statement, a consensus agreement is outlined that describes the benefits of mini-MVS, including reduced postoperative bleeding, reduced wound infection, enhanced recovery and patient satisfaction. Technical considerations require specific attention and can be introduced through simulation and/or use in conventional cases. Either endoballoon or aortic cross clamping is recommended, as well as femoral or central aortic cannulation, with the use of appropriate adjuncts and instruments. A coordinated team-based approach that encourages ownership of the programme by the team members is critical. A designated proctor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases, is an important step to consider. The importance of pre-empting complications and dealing with adverse events is described, including re-exploration, conversion to sternotomy, unilateral pulmonary oedema and phrenic nerve injury. Accounting for both institutional and team considerations can effectively facilitate the introduction of a mini-MVS service. This involves simulation, team-based training, visits to specialist centres and involvement of a designated proctor to oversee the initial cases.
Collapse
Affiliation(s)
- Hunaid A Vohra
- Cardiac Surgery, Bristol Heart Institute, Bristol, Bristol, UK
| | - M Yousuf Salmasi
- Surgery and Cancer, Imperial College London, London, United Kingdom, UK
| | - Lueh Chien
- Faculty of Medicine, Imperial College London, London, London, UK
| | - Max Baghai
- Cardiothoracic Surgery, King's College Hospital NHS Foundation Trust, London, London, UK
| | | | - Enoch Akowuah
- Cardiothoracic Surgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Ishtiaq Ahmed
- Cardiac Surgery, Brighton and Sussex NHS LKS Royal Sussex County Hospital, Brighton, Brighton and Hove, UK
| | | | - Toufan Bahrami
- Cardiac Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Steven Hunter
- Cardaic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Sheffield, UK
| | - Joseph Zacharias
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | | |
Collapse
|
8
|
Yousuf Salmasi M, Hamilton H, Rahman I, Chien L, Rival P, Benedetto U, Young C, Caputo M, Angelini GD, Vohra HA. Mini‐sternotomy vs right anterior thoracotomy for aortic valve replacement. J Card Surg 2020; 35:1570-1582. [DOI: 10.1111/jocs.14607] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | - Lueh Chien
- Department of Surgery Imperial College London London UK
| | - Paul Rival
- Department of Cardiac Surgery Bristol Heart Institute Bristol UK
| | | | | | - Massimo Caputo
- Department of Cardiac Surgery Bristol Heart Institute Bristol UK
| | | | - Hunaid A. Vohra
- Department of Cardiac Surgery Bristol Heart Institute Bristol UK
| |
Collapse
|
9
|
Mohammed H, Yousuf Salmasi M, Caputo M, Angelini GD, Vohra HA. Comparison of outcomes between minimally invasive and median sternotomy for double and triple valve surgery: A meta-analysis. J Card Surg 2020; 35:1209-1219. [PMID: 32306504 DOI: 10.1111/jocs.14558] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to median sternotomy (MS) for multiple valvular disease (MVD). This systematic review and meta-analysis aims to compare operative and peri-operative outcomes of MIS vs MS in MVD. METHODS PubMed, Ovid, and Embase were searched from inception until August 2019 for randomized and observational studies comparing MIS and MS in patients with MVD. Clinical outcomes of intra- and postoperative times, reoperation for bleeding and surgical site infection were evaluated. RESULTS Five observational studies comparing 340 MIS vs 414 MS patients were eligible for qualitative and quantitative review. The quality of evidence assessed using the Newcastle-Ottawa scale was good for all included studies. Meta-analysis demonstrated increased cardiopulmonary bypass time for MIS patients (weighted mean difference [WMD], 0.487; 95% confidence interval [CI], 0.365-0.608; P < .0001). Similarly, aortic cross-clamp time was longer in patients undergoing MIS (WMD, 0.632; 95% CI, 0.509-0.755; P < .0001). No differences were found in operative mortality, reoperation for bleeding, surgical site infection, or hospital stay. CONCLUSIONS MIS for MVD have similar short-term outcomes compared to MS. This adds value to the use of minimally invasive methods for multivalvular surgery, despite conferring longer operative times. However, the paucity in literature and learning curve associated with MIS warrants further evidence, ideally randomized control trials, to support these findings.
Collapse
Affiliation(s)
- Haya Mohammed
- Faculty of Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Massimo Caputo
- Department of Cardiovascular Sciences, Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiovascular Sciences, Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | - Hunaid A Vohra
- Department of Cardiovascular Sciences, Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| |
Collapse
|