Periareolar Access for Minimally Invasive Cardiac Surgery the Brazilian Technique

Minimally Invasive Surgery for Congenital Heart Disease

Minimally invasive cardiac surgery for congenital heart disease has gained increasing acceptance within the specialty. However, most suitable candidates are still treated with a conventional median sternotomy. Adoption of minimally invasive techniques has proven essential in the surgical repair of acquired heart disease to increase patient satisfaction and to remain competitive in an ever-changing medical field. We herein summarize the currently available literature on minimally invasive congenital heart surgery. We describe available techniques and routes of access as well as the lesions amenable for minimally invasive repairs. Mainly derived from case series and smaller retrospective studies, we report available evidence on outcome, especially compared with conventional repairs through a median sternotomy. We highlight the unique challenges that arise from the wide range of lesions as well as from the spectrum of patients, ranging from infant to adulthood, and describe ways to mitigate those.

Minimal Access Tricuspid Valve Surgery

Tricuspid valve diseases are a heterogeneous group of pathologies that typically have poor prognoses when treated medically and are associated with significant morbidity and mortality with traditional surgical techniques. Minimal access tricuspid valve surgery may mitigate some of the surgical risks associated with the standard sternotomy approach by limiting pain, reducing blood loss, lowering the risk of wound infections, and shortening hospital stays. In certain patient populations, this may allow for a prompt intervention that could limit the pathologic effects of these diseases. Herein, we review the literature on minimal access tricuspid valve surgery focusing on perioperative planning, technique, and outcomes of minimal access endoscopic and robotic surgery for isolated tricuspid valve disease.

A randomized controlled trial (PAMI trial) on our new trend periareolar minimally invasive (PAMI) technique versus inframammary approach for minimally invasive cardiac surgery

Background

A minimally invasive approach has become standard for mitral valve surgery. The periareolar approach has grown in popularity regarding the cosmesis for patients. We have adopted a new modification to the periareolar approach: the periareolar minimally invasive (PAMI) technique. The objectives of the current study are to test the hypothesis that the PAMI approach is more feasible and safer than the inframammary approach in addition to identify risk factors and assess outcomes of both periareolar and inframammary approach.

Methods

A randomized controlled trial of 3 months compared the PAMI technique to the inframammary approach for minimally invasive cardiac surgery.

Results

A total of 102 patients were enrolled and randomized into two groups: 53 received minimally invasive cardiac surgery through the periareolar approach, and 49 were the control group using the inframammary approach.

Using intention-to-treat analysis, the periareolar approach was superior to the inframammary approach in surgical site infection (two cases in comparison to 8 with P = 0.004), and the number needed to treat for effectiveness was 8.

No early deaths occurred, 97 cases (95.1%) needed no reoperation, and 5 cases (4.9%) were reopened for bleeding. The primary endpoints compared were the duration of procedure, duration of mechanical ventilation, amount of bleeding, ICU stay, and hospital stay. We found no statistically significant differences between the groups.

At 3 months, the secondary endpoints evaluated were the rate of surgical site infection, respiratory complications, groin complications, pericardial effusion, breast hematoma, and cosmoses using a Likert scale. We found no statistically significant difference between the groups, except for surgical site infection (P = 0.004) and cosmesis (P< 0.001).

Conclusions

The results of this PAMI trial are suggestive that the PAMI technique is most probably applicable for the right side of the heart, such as in atrial septal defect closure, tricuspid disease, and mitral valve surgery.

Trial registration

PAMI Trial NCT04726488 Registered January 27, 2021

Decision Making during the Learning Curve of Minimally Invasive Mitral Valve Surgery: A Focused Review for the Starting Minimally Invasive Surgeon

Minimally invasive mitral valve surgery is evolving rapidly since the early 1990’s and is now increasingly adopted as the standard approach for mitral valve surgery. It has a long and challenging learning curve and there are many considerations regarding technique, planning and patient selection when starting a minimally invasive program. In the current review, we provide an overview of all considerations and the decision-making process during the learning curve.

Triport periareolar thoracoscopic surgery versus right minithoracotomy for repairing atrial septal defect in adults

OBJECTIVES

Our goal was to investigate the safety and feasibility of triport periareolar thoracoscopic surgery (TPTS) and its advantages in repairing adult atrial septal defect.

METHODS

Between January 2017 and January 2020, a total of 121 consecutive adult patients underwent atrial septal defect closure in our institution. Of these, 30 patients had TPTS and 31 patients had a right minithoracotomy (RMT). Operational data and clinical outcomes were compared between the 2 groups.

RESULTS

The total operation time, cardiopulmonary bypass time and aortic cross-clamp time in the TPTS group were slightly longer than those in the RMT group, but there were no differences between the 2 groups. Compared with the RMT group, the TPTS group showed a decrease in the volume of chest drainage in 24 h (98.6 ± 191.2 vs 222.6 ± 217.2 ml; P = 0.032) and a shorter postoperative hospital stay (6.5 ± 1.5 vs 8.0 ± 3.7 days; P = 0.042). The numeric rating scale on postoperative day 7 was significantly less in the TPTS group than in the RMT group (2.82 ± 1.14 vs 3.56 ± 1.42; P = 0.034). The patient satisfaction scale for the cosmetic results in the TPTS group was significantly higher than in the RMT group (4.68 ± 0.55 vs 4.22 ± 0.76; P = 0.012). No differences were found in postoperative complications. No in-hospital death or major adverse events occurred in the 2 groups.

CONCLUSIONS

TPTS is safe and feasible for the closure of adult atrial septal defect. Compared with RMT, it has been associated with less pain and better cosmetic outcomes.

Minimally invasive tricuspid valve surgery

Tricuspid valve disease carries a very unfavorable prognosis when medically treated. Despite that, surgical intervention is still underperformed for tricuspid valve disease due to the reported high morbidity and mortality from a sternotomy approach. This had led to a shift towards maximizing medical therapy for right ventricular failure and, as a result, a more significant delay in surgical referrals with surgical risks when patients are finally referred. Tricuspid valve patients usually have other co-morbidities resulting from their systemic venous congestion and low flow cardiac output. Minimally invasive tricuspid valve surgery provides less tissue injury and, as a result, less trauma during surgery. This provides a hope for both patients and treating doctors to be more open for providing this procedure with less complications. Isolated minimally invasive tricuspid valve surgery is still not performed as widely as expected. This can be partly due to the adverse outcomes historically labelled to tricuspid valve surgery or by the long journey of learning the surgical team would need to commit to with a minimal access approach. In this article we will review the perioperative pathway, and outcomes of isolated minimally invasive tricuspid valve surgery in the available English literature.

Pilot study of totally thoracoscopic periareolar approach for minimally invasive mitral valve surgery. Towards even less invasive?

Introduction

Minimally invasive mitral valve surgery (MIMVS) has become a widely accepted alternative to the standard sternotomy approach for treatment of mitral valve (MV) disease. Because the extent and location of mini-thoracotomies employed for MIMVS vary from center to center, the conclusions regarding superior cosmesis are not generalizable. The totally thoracoscopic periareolar (TTP) – MIMVS technique has been used at our department for minimally invasive cardiac surgery since 2015.

Aim

To report early surgical data as well as mid-term outcomes in patients undergoing TTP-MIMVS.

Material and methods

Between 2015 and 2017, 48 consecutive patients (mean age: 65.4 ±10; 83% men; EuroSCORE II: 5.1 ±4%) underwent TTP-MIMVS due to mitral and mitral/tricuspid valve (TV) disease; patients’ demographics and clinical outcomes were prospectively collected. Kaplan-Meier estimates of survival and freedom from re-intervention were analyzed as well.

Results

Mean follow-up was 1.7 (max 2.5) years. Of 48 patients, 33 (69%) underwent isolated MV repair, 4 (8%) isolated MV replacement and 11 (23%) MV/TV repair. The cardiopulmonary bypass and aortic cross-clamp time was 166 ±70 and 103 ±39 min respectively. There was no conversion to either full sternotomy or a mini-thoracotomy approach. Median (interquartile range) duration of intensive care unit stay was 1.2 (1.0–2.0) days. There was one in-hospital death (2.1%) in the TTP-MIMVS group. No strokes or wound infections were observed. Within the investigated follow-up, the freedom from reoperation rate was 96.4%; remote survival was estimated at 96.9%.

Conclusions

The study proved that TTP-minimally invasive surgery was safe and feasible in mitral and tricuspid valve surgery. It has been associated with superior esthetics. Mitral repairs performed through TTP access are durable in mid-term observation.

Minimally Invasive Periareolar Approach to Cor Triatriatum Repair

Cor triatriatum sinister is an uncommon cardiac abnormality characterized by a membrane that divides the left atrium into two chambers. Definitive management requires surgical resection, traditionally through sternotomy. Minimally invasive reparative techniques are associated with reduced blood loss, shorter hospitalization, faster recovery time, and improved cosmesis with excellent patient satisfaction. We present a 29-year-old woman with cor triatriatum sinister and associated atrial septal defect who underwent successful minimally invasive repair through a right periareolar approach.