Port-access aortic valve replacement

Aortic valve approaches in the era of minimally invasive cardiac surgery

The concept of minimally invasive cardiac surgery has been gradually adopted world-wide since its inception more than 2 decades ago. Recently, catheter intervention has been used in the treatment of structural heart disease. Most notably, minimally invasive transcatheter aortic valve implantation is now an established treatment option for aortic valve stenosis. There are three major approaches for minimally invasive aortic valve surgery: via median sternotomy, via the parasternal approach, and via the thoracotomy approach. All these approaches allow for a small skin incision and/or avoid full sternotomy. Moreover, several advanced variations with additional aortic procedures or totally endoscopic management have been developed. When considering each approach, low invasiveness must be balanced with safety, as surgeons broaden their insight of advanced medicine. Physical invasiveness is largely related to the surgical approach in minimally invasive surgery. We review the history and evolution of the different surgical approaches for minimally invasive aortic valve replacement.

Anterolateral approach for minimally invasive aortic valve replacement

OBJECTIVE

Right anterior thoracotomy is the most common approach of minimally invasive aortic valve replacement (MIAVR) via intercostal mini-thoracotomy. However, there are some disadvantages including sacrificing the right internal thoracic artery (RITA). The aim of the present study was to investigate the efficacy of anterolateral thoracotomy (ALT), which is similar to lateral thoracotomy used for minimally invasive mitral valve surgery, for MIAVR.

METHODS

From October 2012 to June 2013, 21 patients underwent MIAVR through ALT. Perioperative outcome of these patients was compared with those of 59 patients who underwent MIAVR via standard anterior thoracotomy (SAT) from May 2007 to September 2012.

RESULTS

Mean age, body surface area, annular size, the ratio of aortic stenosis, and Japan score (30 days mortality), in ALT group were significantly more severe than those in SAT group. There was no significant difference in operative time; however, cardiopulmonary bypass and cross-clamping times in ALT group were significantly longer than those in SAT group. Significant differences were not found in mortality, morbidity, intubation time, blood transfusion rate, intensive care unit stay, hospital stay, and echocardiographic data such as effective orifice area index between both groups.

CONCLUSIONS

Anterolateral approach has several advantages including no need to sacrifice the RITA and cosmetic benefit in female patients, offering similar results as SAT even with more severe patient characteristics.

Left ventricular thrombectomy using video-assisted thoracoscopy

We report a case of a 40-year-old male who had a left ventricular thrombus with impaired cardiac function. The thrombus was completely removed using a video-assisted thoracoscopy via a right mini-thoracotomy. This approach is less invasive, avoiding sternotomy and ventriculotomy which can cause postoperative complications.

Port-access double valve replacement: first case report in Japan

A 57-year-old man with mitral and aortic valve stenosis was admitted to our hospital. An electrocardiogram showed atrial fibrillation. After receiving informed consent, we performed a double valve replacement (DVR) with bioprostheses and maze procedure, utilizing a port-access technique. The operation and aortic cross-clamping times were 460 and 228 min, respectively. The patient's recovery was uneventful and he was discharged from our hospital with a consistent sinus rhythm 22 days after surgery. This is the first case report of port-access DVR in Japan.

Port-access heart surgery for the treatment of cor triatriatum with atrial septal defect: Report of a case

A 40-year-old woman was admitted because of progressive dyspnea on exertion. Magnetic resonance imaging revealed an atrial septal defect and an abnormal membranous structure separating the left atrium into proximal and distal chambers. Surgical correction was performed by a minimally invasive surgical approach, i.e., port-access heart surgery, under the diagnosis of cor triatriatum (subtype of Lucas Schmidt IIIA1 or IB1) complicated with atrial septal defect. The postoperative course was uneventful, and she was discharged 12 days after surgery. This case is the first report of a surgical correction for cor triatriatum using the port-access technique.

Minimally invasive cardiac surgery for atrial fibrillation complicated by coronary artery disease: combination of video-assisted pulmonary vein isolation and minimally invasive direct coronary artery bypass

Here we report a minimally invasive cardiac surgery procedure without sternotomy combining video-assisted bilateral pulmonary vein isolation and minimally invasive direct coronary artery bypass as treatment for atrial fibrillation complicated by coronary artery disease. The patient's chest was accessed through a left anterolateral thoracotomy over the fourth intercostal space, and the left internal thoracic artery (LITA) was harvested under direct vision. The left pulmonary veins were isolated electrically by a bipolar radiofrequency clamp. Subsequently, the harvested LITA graft was anastomosed to the left anterior descending artery. Right pulmonary vein isolation was then performed through a small thoracotomy at the right fourth intercostal region in the same manner as the left side. A linear block on the left atrial roof, connecting the lesions encircling the left and right pulmonary veins, was created from both sides by a pen-like bipolar radiofrequency.