Late redo-port access surgery after port access surgery

Endoaortic balloon occlusion versus transthoracic cross-clamp for totally endoscopic robotic mitral valve surgery: a retrospective cohort study

Endoaortic balloon occlusion (EABO) and transthoracic cross-clamping have been shown to have comparable safety profiles for aortic occlusion in minimally invasive mitral valve surgery (MIMVS). However, few studies have focused exclusively on the totally endoscopic robotic approach. We sought to compare outcomes for patients undergoing totally endoscopic robotic mitral valve surgery with aortic occlusion via EABO and transthoracic clamping after a period where EABO was unavailable required us to use the transthoracic clamp. Retrospective review identified 113 patients who underwent robotic mitral valve surgery at our facility between 2019 and 2021 with EABO (n = 71) or transthoracic clamping (n = 42). Relevant data were extracted and compared. Preoperative characteristics were similar other than a higher rate of coronary artery disease [EABO: 69.0% (49/71) vs clamp: 45.2% (19/42), p = .02] and chronic lung disease [EABO: 38.0% (27/71) vs clamp: 9.5% (4/42), p < .01] in the EABO group. Median percutaneous cardiopulmonary bypass time, operative time, and cross-clamp time were comparable. Similar rates of postoperative bleeding complications were observed, and no aortic complications were observed. One patient in each group underwent conversion to an open approach. 30-day mortality and readmission rates were comparable. EABO and transthoracic clamp were associated with similar bleeding and aortic outcomes, and mortality and readmission rates were comparable at thirty days postoperatively. Our findings support the comparable safety of the two techniques, which is well documented in studies encompassing all MIMVS techniques, within the specific context of the totally endoscopic robotic approach.

Mitral valve surgery: current status and future prospects of the minimally invasive approach

Introduction: During the past five years the approach to procedural planning, operative techniques and perfusion strategies for minimally invasive mitral valve surgery (MIMVS) has evolved. With the goal to provide a maximum of patient safety the procedure has been modified according to individual patient characteristics and is largely based on preoperative imaging.Areas covered: In this review article we describe the important factors in image based therapy planning and simulation, different access strategies, the operative key-steps, a rationale use of devices, and highlight a few future developments in the field of MIMVS. Published studies were identified through pearl growing, citation chasing, a search of PubMed using the systematic review methods filter, and the authors' topic knowledge.Expert opinion: With the help of expert teams including surgeons specialized in mitral repair, anesthesiologists and perfusionists a broad spectrum of mitral valve pathologies and related pathologies can be treated with excellent functional outcomes. Avoiding procedure related complications is the key for success for any MIMVS program.

Reasons for conversion and adverse intraoperative events in Endoscopic Port Access™ atrioventricular valve surgery and minimally invasive aortic valve surgery

OBJECTIVES

This study reports the factors that contribute to sternotomy conversions (SCs) and adverse intraoperative events in minimally invasive aortic valve surgery (MI-AVS) and minimally invasive Endoscopic Port Access™ atrioventricular valve surgery (MI-PAS).

METHODS

In total, 3780 consecutive patients with either aortic valve disease or atrioventricular valve disease underwent minimally invasive valve surgery (MIVS) at our institution between 1 February 1997 and 31 March 2016. MI-AVS was performed in 908 patients (mean age 69.2 ± 11.3 years, 45.2% women, 6.2% redo cardiac surgery) and MI-PAS in 2872 patients (mean age 64.1 ± 13.3 years, 46.7% women, 12.2% redo cardiac surgery).

RESULTS

A cumulative total of 4415 MIVS procedures (MI-AVS = 908, MI-PAS = 3507) included 1537 valve replacements (MI-AVS = 896, MI-PAS = 641) and 2878 isolated or combined valve repairs (MI-AVS = 12, MI-PAS = 2866). SC was required in 3.0% (n = 114 of 3780) of MIVS patients, which occurred in 3.1% (n = 28 of 908) of MI-AVS patients and 3.0% (n = 86 of 2872) of MI-PAS patients, respectively. Reasons for SC in MI-AVS included inadequate visualization (n = 4, 0.4%) and arterial cannulation difficulty (n = 7, 0.8%). For MI-PAS, SC was required in 54 (2.5%) isolated mitral valve procedures (n = 2183). Factors that contributed to SC in MI-PAS included lung adhesions (n = 35, 1.2%), inadequate visualization (n = 2, 0.1%), ventricular bleeding (n = 3, 0.1%) and atrioventricular dehiscence (n = 5, 0.2%). Neurological deficit occurred in 1 (0.1%) and 3 (3.5%) MI-AVS and MI-PAS conversions, respectively. No operative or 30-day mortalities were observed in MI-AVS conversions (n = 28). The 30-day mortality associated with SC in MI-PAS (n = 86) was 10.5% (n = 9).

CONCLUSIONS

MIVS is increasingly being recognized as the 'gold-standard' for surgical valve interventions in the context of rapidly expanding catheter-based technology and increasing patient expectations. Surgeons need to be aware of factors that contribute to SC and adverse intraoperative outcomes to ensure that patients enjoy the maximum potential benefit of MIVS and to apply effective risk reduction strategies that encourage safer and sustainable MIVS programmes.

Feasibility, safety, and short-term outcome of totally thoracoscopic mitral valve procedure

Background

The totally thoracoscopic procedure for mitral valve (MV) disease is a minimally invasive method. We investigated the procedure’s feasibility, safety and effectiveness when it was performed by an experienced operator.

Methods

We retrospectively analysed 53 consecutive patients with MV disease treated between December 2014 and April 2017 by minimally invasive procedures. The procedures were performed on femoral artery-vein bypass through three 2–4 cm incisions, with one additional penetrating point on the right chest wall under totally thoracoscopic visual guidance and surveillance of transoesophageal echocardiography.

Results

Two patients who underwent intraoperative conversion to sternotomy were excluded due to indivisible pleural cavity adhesion. Of the others (38 female patients, average age, 49 ± 14 years, left ventricular ejection fraction, 59 ± 7%), 34 received MV replacement for rheumatic mitral lesions, which was redone for one patient after the discovery of serious paravalvular leakage, 17 received MV repair for mitral regurgitation (with 4 secondary to atrial septum defect, 2 diagnosed with left atrial myxoma, and 2 redone for mitral valve replacement due to repair failure), 28 received additional tricuspid valvuloplasty, and one patient received a Warden procedure. The cardiopulmonary bypass and aortic cross clamp times were 144 ± 39 min and 80 ± 22 min, respectively. Postoperational chest tube drainage in the first 48 h was 346 ± 316 ml. The ventilation time and intensive care unit stay length were 11 ± 11 h and 23 ± 2 h, respectively. One patient died of disseminated intravascular coagulation and prosthesis thrombosis with fear of anticoagulation-related bleeding.

Conclusions

The totally thoracoscopic procedure on mitral valves by an experienced surgeon is technically feasible, safe, effective and worthy of widespread adoption in clinical practice.

Endoscopic Port AccessTM left ventricle outflow tract resection and atrioventricular valve surgery

The continuous evolution in robotic-, endoscopic- and trans-catheter cardiac interventions resulted in innovative techniques that simultaneously address left ventricular outflow tract obstruction (LVOTO) and concomitant atrioventricular valve (AVV) pathology in the context of hypertrophic obstructive cardiomyopathy (HOCM). We present our brief report of 13 consecutive HOCM patients with concomitant AVV disease, who underwent endoscopic left ventricular septal myomectomy (LVSM) and AVV surgery by Endoscopic Port Access^TM Surgery (EPAS) between March 1st 2010 and October 31st 2015. Our EPAS technique in the context of HOCM utilizes peripheral cardiopulmonary bypass, endo-aortic balloon occlusion and a 4-cm right antero-lateral thoracic working port. Access to the LVOTO is obtained by detaching the anterior mitral valve (MV) leaflet from the annulus. Controlled sharp LVSM is then performed from the aortic leaflet base to the papillary muscles. Subsequent routine AVV surgery is performed using long shafted instruments. There were no sternotomy conversions, LVSM complications or 30-day mortalities. The mean length of hospitalization was 17.7±18.1 days. Long-term clinical and echocardiographic analysis of 645.7 patient-months (n=13, 100.0% complete) identified two late mortalities, which were not procedure-, HOCM- or AVV-related. All patients (n=13, 100.0%), including the late mortalities, had significant improvement in their quality of life, a 100% long-term freedom from re-intervention and no residual peak instantaneous LVOTO gradients more than 15 mmHg. This brief report emphasises that simultaneous LVSM and concomitant AVV surgery by EPAS can safely be performed in experienced centres with favourable long-term outcomes.

Mitral Valve Replacement-Current and Future Perspectives

The favorable outcomes achieved with modern mitral valve repair techniques redefined the role of mitral valve replacement. Various international databases report a significant decrease in replacement procedures performed compared with repairs, and contemporary guidelines limit the application of surgical mitral valve replacement to pathology in which durable repair is unlikely to be achieved. The progressive paradigm shift toward endoscopic and robotic mitral valve surgery is also paralleled by rapid developments in transcatheter devices, which is progressively expanding from experimental approaches to becoming clinical reality. This article outlines the current role and future perspectives of contemporary surgical mitral valve replacement within the context of mitral valve repair and the dynamic evolution of exciting transcatheter alternatives.

Endoscopic atrioventricular valve surgery in adults with difficult-to-access uncorrected congenital chest wall deformities

OBJECTIVES

This study presents the first report on in-hospital and long-term outcomes of endoscopic port access atrioventricular valve surgery (EPAAVVS) in adult patients with uncorrected congenital chest wall deformities (CCWDs).

METHODS

Our current surgical team performed EPAAVVS in 7 consecutive adult patients (mean age 51.3 ± 16.4 years, 14.3% female, 50% older than 60 years, mean EuroSCORE II 0.8 ± 0.1%) with uncorrected CCWDs between 1 November 2009 and 30 November 2015. The mean left ventricular ejection fraction was 66.0 ± 8.5%. Surgical indications included isolated or combined symptomatic mitral valve (MV) regurgitation (n = 7, 100%), left ventricular outflow tract (LVOT) obstruction (n = 1, 14.3%) and patent foramen ovale (n = 3, 42.9%). Fibro-elastic deficiency accounted for 57.1% of MV pathology and 5 patients (74.1%) presented with New York Heart Association (NYHA) Class III symptoms. CCWDs included isolated pectus excavatum (n = 5, 71.4%) and mixed pectus excavatum and carinatum (n = 2, 28.6%). The mean Haller-index and correction index scores were 2.7 ± 0.5 and 21.4 ± 10.2%, respectively.

RESULTS

Procedures performed included MV repair (n = 7, 100%), tricuspid valve (TV) repair (n = 1, 14.3%) and left ventricular septal myomectomy (n = 1, 14.3%). There were no sternotomy conversions or complications with chest wall entry or atrioventricular valve exposure. The mean cardiopulmonary bypass and cross-clamp times were 162.1 ± 48.1 and 113.7 ± 33.5 min, respectively. No patient required mechanical ventilation or intensive care treatment longer than 24 h. There were no surgical revisions, in-hospital respiratory or chest wall morbidities. The mean length of hospital stay was 7.4 ± 1.0 days. A total of 208 patient-months (mean 29.7 ± 26.5) were available for long-term clinical and echocardiographic analysis. There were no 30-day or long-term mortalities and no patient required reintervention for residual atrioventricular valve pathology. All patients were classified as NYHA I during recent consultations, and echocardiographic follow-up confirmed no residual MV regurgitation greater than Grade 1 in any patient.

CONCLUSIONS

EPAAVVS in adults with uncorrected CCWD is safe, feasible and durable and can successfully be performed by experienced teams to achieve Haller index and correction index scores of up to 3.3 and 38.3%, respectively, with favourable long-term clinical and echocardiographic outcomes. The mere presence of uncorrected CCWDs should not deter surgeons from offering these patients the full benefits of minimally invasive cardiac surgery.