Initial large-dose administration of modified St. Thomas' solution

Cell salvage processing of residual cardiopulmonary bypass volume in minimally invasive cardiac surgery

Several reports demonstrated positive effects of processing residual cardiopulmonary bypass volume using a cell salvage device in conventional open heart surgery via sternotomy on hemostasis. The present study aimed to investigate whether cell salvage processing has the same effects on postoperative blood loss and transfusion in minimally invasive cardiac surgery. Between July 2015 and April 2018, 80 consecutive patients undergoing minimally invasive aortic valve replacement via right anterolateral minithoracotomy were enrolled in the present study. Perioperative outcomes and coagulation data of 40 patients who were retransfused with processed cardiopulmonary bypass volumes were compared with those of 40 patients receiving unprocessed residual blood (control group). Postoperative blood loss in patients receiving processed residual blood was significantly less than that in the control group at 6 h (115 ± 50 vs. 73 ± 33 ml, p < 0.001) and 12 h (167 ± 70 vs. 125 ± 67 ml, p = 0.009) after surgery, and the rate of fresh frozen plasma use after surgery was significantly reduced in patients receiving processed residual blood (18 vs. 0%, p = 0.012). In conclusion, processing of residual cardiopulmonary bypass volume reduced postoperative blood loss and postoperative use of fresh frozen plasma and could be useful for hemostasis in minimally invasive cardiac surgery.

Minimally invasive aortic valve replacement through a right anterolateral mini-thoracotomy for the treatment of octogenarians with aortic valve stenosis

Because of concerns about the high risk of perioperative complications, the feasibility of minimally invasive aortic valve replacement (MIAVR) for elderly patients remains controversial. Here, we review our results of MIAVR in octogenarians with aortic valve stenosis (AS). Between October 2012 and December 2017, 110 patients with AS underwent MIAVR via a right anterolateral mini-thoracotomy; 41 patients were octogenarian (Group O). The perioperative outcomes of these patients were compared with those of the 69 patients who were less than 80 years of age (Group Y). A preoperative contrast-enhanced computed tomography (CT) scan was performed in all patients to guide the patient selection and aid the decision regarding cannulation sites. Among all cases of isolated aortic valve replacement, MIAVR accounted for 47% cases during this study period. The mean age of Group O was 83.6 ± 2.9 years, with a maximum age of 89. In Group O, there were no in-hospital deaths or morbidity, including stroke. The rate of blood transfusion was significantly higher in Group O than in Group Y (P = 0.01). However, there was no significant difference in ventilation time, the length of intensive care unit stay, the length of hospital stay, or in the rates of cumulative survival and freedom from valve-related complications. With careful patient selection and a perfusion strategy based on preoperative CT scan, equivalent outcomes of MIAVR were even achieved in octogenarians.

Hypertrophic aortic branches can potentially cause critical problems during minimally invasive cardiac surgery

Here we present two cases in which hypertrophic aortic branches caused trouble during minimally invasive cardiac surgery. We performed mitral valvuloplasty with the Maze procedure in Case 1 and mitral valvuloplasty with aortic valve replacement in Case 2 via mini-thoracotomy. In preoperative computed tomography scan, we did not note a hypertrophic bronchial artery in Case 1 or a dilated intercostal artery in Case 2. The right atrium was distended after aortic cross-clamping and perioperative myocardial infarction occurred in Case 1. Whereas, we could effectively deal with this situation in Case 2. The increased pulmonary blood flow can potentially cause critical problems during minimally invasive surgery. Sufficient venting of the right ventricle and secure myocardial protection is the key to perform safe surgery in the presence of dilated aortic branches. However, surgeons should not hesitate to convert to sternotomy under poor surgical exposure despite sufficient venting.