Minimally invasive surgical aortic valve replacement

Initial experience and favorable outcomes on cannulation strategies and surgical platform construction in fully video-assisted thoracoscopic cardiac surgery

Background

Minimally invasive cardiac surgery offers numerous advantages that patients and surgeons desire. This surgical platform encompasses cannulation strategies for cardiopulmonary bypass, optimal surgical access points, and high-quality visualization techniques. Traditional peripheral cannulation methods, though convenient, possess inherent limitations and carry the potential for complications such as retrograde dissection, stroke, or neurologic sequelae. Conversely, central cannulation may be ideally suited to circumvent the disadvantages above. Fully video-assisted thoracoscopy cardiac surgery represents a state-of-the-art platform, offering surgeons an unparalleled surgical view. This analysis aimed to delineate the efficacy and safety of transthoracic central cannulation strategies and the surgical platform during fully video-assisted thoracoscopy cardiac surgery.

Methods

Between October 2022 and February 2024, we identified a cohort of 85 consecutive patients with cardiopulmonary bypass undergoing fully video-assisted thoracoscopy cardiac surgery at our institutions. The patients' mean age was 41.09 ± 14.01 years, ranging from 18 to 75 years. The mean weight was 64.34 ± 10.59 kg (ranging from 49 to 103 kg). Congenital heart disease repair accounted for the highest proportion, with 43 cases (50.59%). Mitral valve surgery and left atrium Myxoma resections accounted for 29.41%. Specifically, this included 14 mitral valve repairs, five mitral valve replacements, and six left atrium myxoma resections. Aortic valve replacements constitute 20% of all cases.

Results

A total of 85 adult patients underwent fully video-assisted thoracoscopy cardiac surgery. The average CPB time was 83.26 ± 28.26 min, while the aortic cross-clamp time averaged 51.87 ± 23.91 min. The total operation time (skin to skin) averaged 173.8 ± 37.08 min. The mean duration of mechanical ventilation was 5.58 ± 3.43 h, ICU stay was 20.04 ± 2.83 h (ranging from 15.5 to 34 h), and postoperative hospital stay was 5.55 ± 0.87 days. No patients required conversion to thoracotomy and unplanned reoperations due to various reasons. There were no in-hospital deaths, strokes, myocardial infarctions, aortic dissections, or renal failure. No patient developed wound soft tissue infection.

Conclusions

Fully video-assisted thoracoscopy cardiac surgery utilizing central cannulation strategies is a reliable, cost-effective platform with a low risk of complications and a potential solution for patients facing contraindications for peripheral cannulation.

Comparative efficacy of totally thoracoscopic, mini-thoracotomy, and mini-sternotomy approaches in aortic valve replacement

Aortic valve replacement (AVR) is a critical procedure for patients with aortic valve diseases. This study compares the effectiveness of three minimally-invasive surgical approaches for AVR: totally thoracoscopic (TT), right anterior mini-thoracotomy, and upper mini-sternotomy. We analyzed retrospective data from 130 patients who underwent one of these surgeries, focusing on various factors such as duration of hospital stay, operation time, times for cardiopulmonary bypass and aortic cross-clamping, postoperative complications, levels of cardiac biomarkers, pain intensity using the Visual Analog Scale, and mid-term survival rates. Results show that while the TT method had the longest operation times, it also had the shortest hospital stays and faster pain reduction post-surgery. Although the TT group initially showed higher cardiac biomarker levels after surgery, these levels normalized by the third day, similar to the other groups. There were no significant differences in mid-term survival and major adverse cardiac and cerebrovascular event (MACCE) rates among the groups. These findings suggest that the TT method, despite longer surgical times, offers a quicker initial recovery, making it a viable option for AVR.

Minimal Learning Curve for Minimally Invasive Aortic Valve Replacement

BACKGROUND

 Minimally invasive aortic valve replacement (MiAVR) is an established technique for surgical aortic valve replacement (AVR). Although MiAVR was first described in 1993 and has shown good results compared with full sternotomy AVR (FSAVR) only a minority of patients undergo MiAVR. We recently started using MiAVR via an upper hemisternotomy. We aimed to examine the early results of our initial experience with this technique.

METHODS

 We compared 55 MiAVR patients with a historical cohort of 142 isolated FSAVR patients (December 2016-December 2022). The primary outcome was in-hospital mortality. Secondary outcomes included cardiopulmonary bypass (CPB) and cross-clamp times, blood product intake, in-hospital morbidity, and length of intensive care unit and hospital stay.

RESULTS

 There was no significant difference in preoperative characteristics, including age, laboratory values, and comorbidities. There was no significant difference between the groups regarding in-hospital mortality (FSAVR 3.52 vs. MiAVR 1.82%). There was no significant difference in CPB time (FSAVR 103.5 [interquartile range: 82-119.5] vs. MiAVR 107 min [92.5-120]), aortic cross-clamp time (FSAVR 81 [66-92] vs. MiAVR 90 min [73-99]), and valve size (FSAVR 23 [21-25] vs. MiAVR 23 [21-25]). The incidence of intraoperative blood products transfusion was significantly lower in the MiAVR group (10.91%) compared with the FSAVR group (25.35%, p = 0.03).

CONCLUSION

 Our findings further establish the possibility of reducing invasiveness of AVR without compromising patient safety and clinical outcomes. This is true even in the learning curve period and without requiring any significant change in the operative technique and dedicated equipment.

Minimally Invasive Approach for Replacement of the Ascending Aorta towards the Proximal Aortic Arch

Objectives: In recent years, minimally invasive approaches have been used with increasing frequency, even for more complex aortic procedures. However, evidence on the practicability and safety of expanding minimally invasive techniques from isolated operations of the ascending aorta towards more complex operations such as the hemiarch replacement is still scarce to date. Methods: A total of 86 patients undergoing elective surgical replacement of the ascending aorta with (n = 40) or without (n = 46) concomitant proximal aortic arch replacement between 2009 and 2023 were analyzed in a retrospective single-center analysis. Groups were compared regarding operation times, intra- and postoperative complications and long-term survival. Results: Operation times and ventilation times were significantly longer in the hemiarch replacement group. Despite this, no statistically significant differences between the two groups were observed for the duration of the ICU and hospital stay and postoperative complication rates. At ten-year follow-up, overall survival was 82.6% after isolated ascending aorta replacement and 86.3% after hemiarch replacement (p = 0.441). Conclusions: Expanding the indication for minimally invasive aortic surgery towards the proximal aortic arch resulted in comparable postoperative complication rates, length of hospital stay and overall long-term survival compared to the well-established minimally invasive isolated supracommissural ascending aorta replacement.

Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis

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.

Impact of Pleural Integrity Preservation After Minimally Invasive Aortic Valve Surgery

OBJECTIVE

While the benefits of minimally invasive aortic valve surgery compared with standard sternotomy have been widely described, the impact of preservation of pleural integrity (PPI) in minimally invasive surgery is still widely discussed. This study aims to define the role of PPI on postoperative and long-term outcomes after minimally invasive aortic valve replacement (MIAVR).

METHODS

All 2,430 consecutive patients undergoing MIAVR (ministernotomy or right anterior minithoracotomy) between 1997 and 2022 were included in the study. Patients were divided into 2 groups: patients with and without PPI. PPI was considered the maintenance of the pleura closed without the need for a chest tube insertion at the end of the surgical procedure. A propensity-matched analysis was used to compare the PPI and not-PPI groups.

RESULTS

After propensity matching, 848 patients were included in each group (PPI and not-PPI). The mean age was 70.21 versus 71.42 years, and the mean Society of Thoracic Surgeons predicted risk of mortality was 0.31% versus 0.30% in not-PPI versus PPI, respectively. The mean follow-up time was 147.4 months. Postoperatively, not-PPI versus PPI patients had a longer intensive care unit stay (9.7 vs 17.3 h, P < 0.001) and hospital length of stay (5.2 vs 8.9 days, P < 0.001). The rate of respiratory complications including the incidence of pneumothorax or subcutaneous emphysema, pulmonary atelectasis, and pleural effusion events requiring thoracentesis/drainage was significantly higher in not-PPI versus PPI. The 30-day all-cause mortality was higher in not-PPI versus PPI (0.029 vs 0.010, P = 0.003). Perioperative, short-term, and long-term all-cause mortality was significantly higher in the not-PPI group.

CONCLUSIONS

PPI after MIAVR is associated with reduced incidence of postoperative complications, reduced lengths of stay, and improved overall survival compared with not-PPI. Therefore, a MIAVR tailored patient-procedure approach to maintaining the pleura integrity positively impacts short-term and long-term outcomes.

The Perceval Sutureless Bioprosthetic Aortic Valve: Evolution of Surgical Valve Technology

OBJECTIVE

The surgical treatment of aortic stenosis continues to evolve, and sutureless aortic valve replacement (SUAVR) is an emerging technology. With the Perceval S (Corcym, London, UK) as the only true sutureless valve on the market, the objective of this review is to analyze the current literature on Perceval S. Focusing on valve design and deployment as well as applications of the technology for challenging pathology, clinical outcomes are assessed, including a comparison with transcatheter AVR (TAVR).

METHODS

PubMed and MEDLINE were searched by 3 authors for studies analyzing SUAVR from inception to May 19, 2023.

RESULTS

SUAVR facilitates minimally invasive surgery and offers an alternative strategy for patients with small aortic annuli. It also has a time-saving advantage for patients who require complex operations. SUAVR results in excellent long-term morbidity, mortality, durability, and hemodynamic function. In comparison with conventional surgical AVR (SAVR), SUAVR does have a greater risk of postoperative pacemaker implantation; however, increasing user experience and refinements in implantation technique have contributed to reductions in this outcome. SUAVR results in morbidity and mortality that is similar to rapid-deployment AVR. Midterm outcomes are superior to TAVR; however, further robust investigation into all of these comparisons is ultimately necessary.

CONCLUSIONS

SUAVR bridges the gap in technology between SAVR and TAVR. The application of this exciting technology will undoubtedly grow in the coming years, during which additional investigation is paramount to optimize preoperative planning, valve deployment, and reintervention strategies.

New approach for combined aortic valve and coronary procedures through the left anterior minithoracotomy

OBJECTIVES

We have developed a novel technique for accessing the aortic valve (AoV) through the left anterior minithoracotomy (LAmT). This approach has been used in patients requiring both AoV surgery and coronary artery bypass grafting (CABG).

METHODS

From April 2023 to July 2023, we performed 6 concomitant AoV procedures and CABG through the LAmT. The mean age was 71.5 [standard deviation (SD): 5.8; 64; 82] years, and the mean left ventricular ejection fraction was 53% (SD: 12.1; 30; 60). Surgical technique includes LAmT in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic cross-clamping using transthoracic clamp, cold blood cardioplegia, conventional oblique aortotomy and special surgical exposure manoeuvres, aimed to position the ascending aorta and AoV close to the surgical incision.

RESULTS

AoV was effectively visualized and the procedure was performed as planned in all 6 patients. No conversion to sternotomy was required. AoV replacement with biological prosthesis was performed in 6 (100%) patients. Conventional surgical instruments were used in all cases. The long-shafted instruments were not required. Knot-pusher was used in 4 (67%)cases. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomosis was 2.0 (SD: 0.6; 1; 3). Total operation time was 371 (SD: 43; 300; 420) min, cardiopulmonary bypass time was 253 (SD: 36; 193; 284) min and cross-clamp time was - 162 (SD: 29; 128; 214) min. intensive care unit stay was-1.5 (SD: 0.55; 1; 2) days, total hospital stay was-7.3 (SD: 1; 6; 9) days. There were no revisions for bleeding, no strokes or other major complications, and no hospital or 30-days mortality.

CONCLUSIONS

The simultaneous performance of AoV replacement and multivessel CABG through a single left anterior thoracotomy is technically feasible and can be carried out by experienced surgeons. However, a larger number of cases are required to fully comprehend the potential limitations of this procedure.

Expanding the Minimally Invasive Approach towards the Ascending Aorta-A Practical Overview of the Currently Available Techniques

Minimally invasive techniques have gained immense importance in cardiovascular surgery. While minimal access strategies for coronary and mitral valve surgery are already widely accepted and often used as standard approaches, the application of minimally invasive techniques is currently expanded towards more complex operations of the ascending aorta as well. In this new and developing field, various techniques have been established and reported ranging from upper hemisternotomy approaches, which allow even extensive operations of the ascending aorta to be performed through a minimally invasive access to sternal sparing thoracotomy strategies, which completely avoid sternal trauma during ascending aorta replacements. All of these techniques place high demands on patient selection, preoperative planning, and practical surgical implementation. Application of these strategies is currently limited to high-volume centers and highly experienced surgeons. This narrative review gives an overview of the currently available techniques with a special focus on the practical execution as well as the advantages and disadvantages of the currently available techniques. The first results demonstrate the practicability and safety of minimally invasive techniques for replacement of the ascending aorta in a well-selected patient population. With success and complication rates comparable to classic full sternotomy, the proof of concept for minimally invasive replacement of the ascending aorta is now achieved.

Sternal-Sparing Surgical Options in Combined Aortic Valve and Coronary Artery Disease: Proof of Concept

OBJECTIVE

The standard management of concomitant aortic valve (AV) and coronary artery disease has been coronary artery bypass and AV replacement (AVR). With the advent of minimally invasive options, many isolated lesions have been successfully managed using a sternal-sparing approach. In our institution, patients with isolated AV disease are offered minimally invasive surgical or transcatheter AVR, and those with isolated coronary artery disease are routinely managed with robotic totally endoscopic coronary artery bypass or percutaneous coronary intervention. Various combinations of these techniques can be used when a sternal-sparing posture is desired because of patient risk or preference. The aim of this study was to review the outcomes in patients with combined AV and coronary disease who were managed using sternal-sparing approaches.

METHODS

We reviewed the records of 10 patients in our minimally invasive surgical database who presented with concomitant AV and coronary artery disease and underwent combined sternal-sparing management of these 2 lesions using various combinations of minimally invasive approaches.

RESULTS

Four patients had totally endoscopic coronary artery bypass and minimally invasive AVR at the same time, 2 patients underwent transcatheter AVR followed by totally endoscopic coronary artery bypass, and 4 patients underwent minimally invasive AVR with percutaneous coronary intervention. There was no 30-day mortality. The duration of postoperative surgical hospital stay was 3.1 ± 0.9 days.

CONCLUSIONS

Sternal-sparing approaches in combined AV and coronary artery disease are feasible with patient-specific treatment selection of minimally invasive techniques.

Network Meta-Analysis Comparing Transcatheter, Minimally Invasive, and Conventional Surgical Aortic Valve Replacement

The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but time-varying outcomes have yet to be comprehensively explored. This study aimed to compare the all-cause mortality among 3 AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional AVR (CAVR). An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI with CAVR and RCTs or propensity score-matched (PSM) studies comparing MIAVR with CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality were derived from graphical reconstruction of Kaplan-Meier curves. Pairwise comparisons and network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk, as well as patients who underwent transfemoral (TF) TAVI. A total of 27 studies with 16,554 patients were included. In the pairwise comparisons, TAVI showed superior mortality to CAVR until 37.5 months, beyond which there was no significant difference. When restricted to TF TAVI versus CAVR, a consistent mortality benefit favoring TF TAVI was seen (shared frailty hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.76 to 0.98, p = 0.024). In the network meta-analysis involving majority PSM data, MIAVR demonstrated significantly lower mortality than TAVI (HR = 0.70, 95% CI = 0.59 to 0.82) and CAVR (HR = 0.69, 95% CI = 0.59 to 0.80); this association remained compared with TF TAVI but with a lower extent of benefit (HR = 0.80, 95% CI = 0.65 to 0.99). In conclusion, the initial short- to medium-term mortality benefit for TAVI over CAVR was attenuated over the longer term. In the subset of patients who underwent TF TAVI, a consistent benefit was found. Among majority PSM data, MIAVR showed improved mortality compared with TAVI and CAVR but less than the TF TAVI subset, which requires validation by robust RCTs.

Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery

OBJECTIVES

Ministernotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.

METHODS

The data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).

RESULTS

After propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan-Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).

CONCLUSIONS

Minimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.

Mini-sternotomy versus full sternotomy for isolated aortic valve replacement: A single-center experience

BACKGROUND

Minimally invasive approaches to isolated aortic valve replacement (AVR) are well-described and widely utilized. While there are numerous proposed benefits, there is limited literature describing significant morbidity or mortality benefits for minimally invasive isolated AVR resulting in hesitancy in its universal adoption. In this retrospective study, we compare the 5-year outcomes of patients undergoing isolated AVR via full sternotomy (FS) or mini-sternotomy (MS).

METHODS

756 patients underwent isolated AVR between 2014 and 2019. Propensity matching resulted in 142 matched pairs that received either FS or MS. The primary outcome was mortality during the follow-up period. Secondary outcomes included intraoperative variables and postoperative morbidity.

RESULTS

Intraoperative variables including total operative, cardiopulmonary bypass, and aortic cross-clamp times did not differ significantly between groups. Postoperative mortality was similar between the matched groups with nonsignificant differences at 30 days (2.12% vs. 1.4%, p = .657), 1 year (4.9% vs. 2.1%, p = .0.223), and 5 years (7.5% vs. 3.5%, p = .174). Rates of postoperative morbidity were comparable between groups with no significant differences.

CONCLUSION

This study examined the long-term outcomes of propensity-matched patients undergoing isolated AVR via FS or MS and identified no significant differences in outcomes over a 5-year follow-up period. The decision for surgical approach is multifactorial and should be decided on a case-by-case basis taking into consideration patient anatomy, surgeon experience, and comfort, as well as patient preference.

Toward Fluoro-Free Interventions: Using Radial Intracardiac Ultrasound for Vascular Navigation

Transcatheter cardiovascular interventions have the advantage of patient safety, reduced surgery time and minimal trauma to the patient's body. Transcathether interventions, which are performed percutaneously, are limited by the lack of direct line of sight with the procedural tools and the patient anatomy. Therefore, such interventional procedures rely heavily on image guidance for navigating toward and delivering therapy at the target site. Vascular navigation via the inferior vena cava, from the groin to the heart, is an imperative part of most transcatheter cardiovascular interventions including heart valve repair surgeries and ablation therapy. Traditionally, the inferior vena cava is navigated using fluoroscopic techniques such as venography and computed tomography venography. These X-ray-based techniques can have detrimental effects on the patient as well as the surgical team, causing increased radiation exposure, leading to risk of cancer, fetal defects and eye cataracts. The use of a heavy lead apron has also been reported to cause back pain and spine issues, thus leading to interventionalist's disc disease. We propose the use of a catheter-based ultrasound augmented with electromagnetic tracking technology to generate a vascular roadmap in real time and perform navigation without harmful radiation. In this pilot study, we used spatially tracked intracardiac echocardiography to reconstruct a vessel from a phantom in a 3-D virtual environment. We illustrate how the proposed ultrasound-based navigation will appear in a virtual environment, by navigating a tracked guidewire within the vessels in the phantom without any radiation-based imaging. The geometric accuracy is assessed using a computed tomography scan of the phantom, with a Dice coefficient of 0.79. The average distance between the surfaces of the two models comes out to be 1.7 ± 1.12 mm.

A Decision-Support Informatics Platform for Minimally Invasive Aortic Valve Replacement

Minimally invasive aortic valve replacement is performed by mini-sternotomy (MS) or less invasive right anterior mini-thoracotomy (RT). The possibility of adopting RT is assessed by anatomical criteria derived from manual 2D image analysis. We developed a semi-automatic tool (RT-PLAN) to assess the criteria of RT, extract other parameters of surgical interest and generate a view of the anatomical region in a 3D space. Twenty-five 3D CT images from a dataset were retrospectively evaluated. The methodology starts with segmentation to reconstruct 3D surface models of the aorta and anterior rib cage. Secondly, the RT criteria and geometric information from these models are automatically and quantitatively evaluated. A comparison is made between the values of the parameters measured by the standard manual 2D procedure and our tool. The RT-PLAN procedure was feasible in all cases. Strong agreement was found between RT-PLAN and the standard manual 2D procedure. There was no difference between the RT-PLAN and the standard procedure when selecting patients for the RT technique. The tool developed is able to effectively perform the assessment of the RT criteria, with the addition of a realistic visualisation of the surgical field through virtual reality technology.

Converging rapid deployment prostheses with minimal access surgery: analysis of early outcomes

Background

Sutureless prostheses may have added benefit when combined with minimal access surgery, although this has not been fully assessed in the literature. This study aims to provide a comparative analysis of the Perceval valve comparing median sternotomy (MS) with mini-sternotomy (MIS).

Methods

A retrospective analysis of prospectively collected data was conducted for all isolated aortic valve replacement (AVR), using the Perceval valve, for severe aortic stenosis cases in the period 2014 to 2019. Patients undergoing concomitant valve or revascularisation surgery were excluded.

Results

A total of 78 patients were included: MS group 41; MIS group 37. Operatively, bypass times were comparable between MS and MIS groups (mean 89.3 vs 83.4, p = 0.307), as were aortic cross clamp times (58.4 vs 55.9, p = 0.434). There were no operative deaths or new onset post-operative neurology. MIS was a predictor of reduced stay in the intensive care unit (coef − 3.25, 95% CI [− 4.93, − 0.59], p = 0.036) and hospital stay overall (p = 0.004). Blood transfusion units were comparable as were the incidence of heart block (n = 5 vs n = 3, p = 0.429) and new onset atrial fibrillation (n = 15 vs n = 9, p = 0.250). Follow-up echocardiography found a significant improvement in effective orifice area, left ventricular dimension and volume indices, and LVEF (p > 0.05) for all patients. Multivariate analysis found mini-sternotomy to be a predictor for reduced LV diastolic volume (coef − 0.35, 95% CI [− 1.02, − 0.05], p = 0.05).

Conclusions

The combination of minimal access surgery and sutureless AVR may enhance patient recovery and provide early LV remodelling.

Pulmonary Valve Replacement and Redo Pulmonary Valve Replacement via Ministernotomy - How to do it

Minimally invasive cardiac surgery is mainly dedicated to acquired left-sided valve diseases. Ministernotomy is widely used for aortic valve repair or replacement, whereas pulmonary valve repair via this approach has been reported only recently. This article aims to describe the use of ministernotomy for pulmonary valve replacement in adult congenital patients.

An ex vivo evaluation of two different suture techniques for the Ozaki aortic neocuspidization procedure

 

OBJECTIVES

We investigated the Ozaki procedure using a single interrupted suture technique (SST) and compared this with the standard continuous suture technique (CST) with regard to hydrodynamic valve performance. In addition, both techniques were compared with the native aortic valve (NAV).

METHODS

Effective orifice area, mean pressure gradient and leakage volume were evaluated in the NAV as well as after an Ozaki procedure using SST or CST in fresh swine aortic roots using a mock circulation loop. The NAV, SST and CST were evaluated under 4 defined hydrodynamic conditions.

RESULTS

Both suture techniques resulted in a similar effective orifice area under all conditions [for stroke volume of 70 ml: SST: 1.50 (1.35-1.87) vs CST: 1.57 (1.41-1.72) cm2, P = 0.8] and there were no significant differences between both suture techniques and the NAV (P > 0.05). Regarding mean pressure gradient, the Ozaki procedure with SST and CST showed no significant differences [7.23 (5.53-8.91) vs 7.04 (6.65-7.60) mmHg, P = 0.72] and there was no significant difference between both suture techniques and the NAV (P > 0.1). In leakage volume, there was no significant difference between SST and CST [4.49 (3.91-4.99) vs CST: 4.23 (3.58-4.87) ml/stroke, P = 0.34].

CONCLUSIONS

The Ozaki procedure with SST performed similarly to that with CST with regard to hydrodynamic performance. Our results suggest that the Ozaki procedure can be performed with SST instead of CST, which may be useful in patients with limited surgical exposure, such as a small annulus.

Clinical study of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision: The first Chinese experience

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.

How the COVID-19 pandemic changed treatment of severe aortic stenosis: a single cardiac center experience

Background

Currently, two effective therapeutic options for severe aortic stenosis (AS) are available, one catheter-based [transcatheter aortic valve implantation (TAVI)], the other open surgical approach [surgical aortic valve replacement (SAVR)]. The COVID-19 pandemic has limited the availability of medical procedures. The purpose of this cross-sectional study was to assess if this pandemic had any impact on the treatment strategy of severe AS in a single cardiac center.

Methods

This study involved AS patients treated in 3-month periods (February through April) over 3 consecutive years 2018, 2019 [defined as COV(-) group] and 2020 [COV(+)]. We assessed if there were any differences regarding patients' clinical profile, applied therapeutic method, procedure complexity and early clinical outcomes.

Results

In the years 2018 through 2019, approximately 50% of AS patients were treated classically (SAVR) while in 2020 this rate dropped to 34%. The preoperative clinical characteristic of TAVI subjects was comparable irrespective of the year. Regarding SAVR, more patients in COV(+) underwent urgent and more complex procedures. More of them were found in NYHA class III or IV, and had lower left ventricular ejection fraction (LVEF) (51.9%±14.4% vs. 58.3%±8.1%; P=0.021) than in COV(-) individuals. During the pandemic, a change in applied therapeutic methods and differences in patients' clinical profile did not have an unfavorable impact on in-hospital mortality (2.0% before vs. 3.6% during pandemic) and morbidity. Of note, intubation time and in-hospital stay were significantly shorter (P<0.05) in 2020 (4.2 hours and 7.5 days) than in the previous years (7.5 hours and 9.0 days, respectively).

Conclusions

The coronavirus pandemic has changed substantially the management of severe AS. The shift into less invasive treatment method of AS patients resulted in shortening of in-hospital stay without compromise of short-term outcomes.

Early Outcomes of Isolated Aortic Valve Replacement Through Right Anterior Minithoracotomy Using the Latest-Generation Biological Prosthesis

OBJECTIVE

The aim of this study is to evaluate early and intermediate outcomes and hemodynamics of the latest-generation Trifecta valve implanted using right anterior minithoracotomy.

METHODS

We performed a single-center, retrospective, observational study including 175 individuals who underwent isolated minimally invasive aortic valve replacement with the latest-generation Trifecta valves through a right anterior minithoracotomy between January 2016 and January 2019. Exclusion criteria for follow-up echocardiographic study included concomitant procedures, conversion to median sternotomy, and nonsurvival during the index admission. Analyses addressed implantation safety, 30-day and intermediate-term survival and hemodynamic performance of the valves.

RESULTS

Overall, patients were followed with duration ranging from 0.5 to 3 years. Early (<30 days) mortality occurred in 2 patients (1.1%), and there were 9 (5.1%) late (>30 days) deaths. Early thromboembolic events and postoperative bleeding requiring reoperation occurred at a rate of 4.0% (n = 7) and 6.2% (n = 11), respectively. Overall in 175 patients who met inclusion criteria for the follow-up echocardiography study, mean gradients across all valve sizes were 41.3 ± 14.9 (standard deviation) mm Hg preoperatively and remained low at 7.2 ± 3.9 mm Hg with mean effective orifice area of 1.8 ± 0.5 cm² on the last follow-up echo. There was 1 case of infective prosthetic endocarditis, which did not require valve explant. There were no reoperations due to valve-related problems during the study period.

CONCLUSIONS

This is the largest series reporting on outcomes of the latest-generation Trifecta valve implanted using right anterior minithoracotomy. Our results demonstrate that this valve can be safely implanted via a minimally invasive approach with excellent early and intermediate outcomes and hemodynamic performance.

Black phosphorus-based 2D materials for bone therapy

Since their discovery, Black Phosphorus (BP)-based nanomaterials have received extensive attentions in the fields of electromechanics, optics and biomedicine, due to their remarkable properties and excellent biocompatibility. The most essential feature of BP is that it is composed of a single phosphorus element, which has a high degree of homology with the inorganic components of natural bone, therefore it has a full advantage in the treatment of bone defects. This review will first introduce the source, physicochemical properties, and degradation products of BP, then introduce the remodeling process of bone, and comprehensively summarize the progress of BP-based materials for bone therapy in the form of hydrogels, polymer membranes, microspheres, and three-dimensional (3D) printed scaffolds. Finally, we discuss the challenges and prospects of BP-based implant materials in bone immune regulation and outlook the future clinical application.

Right anterior minithoracotomy approach for resection of papillary fibroelastoma

BACKGROUND

Right anterior minithoracotomy (RAMT) is an alternative to full or partial sternotomy for accessing the aortic valve. The adoption of this approach for aortic valve replacement has been limited by its perceived technical complexity. Resection of a mobile aortic valve tumor is a simple procedure that is conventionally done through a sternotomy.

AIM

The following case describes the resection of an aortic valve papillary fibroelastoma through an RAMT.

MATERIALS & METHODS

This is a report on a single patient's case.

RESULTS

The fibroelastoma was safely excised through a RAMT approach.

DISCUSSION

An aortic valve fibroelastoma offers an ideal starting point for surgeons to begin using a RAMT approach.

CONCLUSION

The excision of aortic valve masses is a procedure that is well suited to minimally invasive strategies, and we suggest sternum-sparing RAMT is the optimal approach.