Minimally Invasive Cardiac Surgery versus Conventional Median Sternotomy for Atrial Septal Defect Closure

Technique and early outcomes of total thoracoscopic double-valve replacement

Objective

Reports on aortic and mitral double-valve replacement through total thoracoscopy are scarce, with surgical techniques constantly evolving. We aimed to compare the feasibility and safety between total thoracoscopic double-valve replacement and median sternotomy double-valve replacement.

Methods

From November 2021 to March 2023, we performed double-valve replacements in 76 patients using the total thoracoscopic double-valve replacement. The control group comprised 77 patients who underwent median sternotomy double-valve replacement. We analyzed data on baseline characteristics, perioperative events, and early postoperative outcomes.

Results

In the total thoracoscopic double-valve replacement group, the cardiopulmonary bypass and aortic crossclamping times were 174.20 ± 38.87 minutes and 120.20 ± 19.54 minutes, respectively; both were significantly longer compared with those in the median sternotomy double-valve replacement group (cardiopulmonary bypass: 123.65 ± 15.33 minutes; aortic crossclamping: 82.86 ± 9.51 minutes, P < .001). The total thoracoscopic double-valve replacement group exhibited an extended operative duration, with a mean of 4.40 ± 0.76 hours, in contrast to 3.21 ± 0.68 hours in the median sternotomy double-valve replacement group (P < .001). Postoperatively, the total thoracoscopic double-valve replacement group demonstrated a significantly shorter mechanical ventilation duration (9.29 ± 3.12 hours) and reduced intensive care unit stay time (24.31 ± 7.29 hours) than the median sternotomy double-valve replacement group (11.49 ± 4.27 hours and 26.76 ± 5.89 hours, respectively; P values of .019 and .040, respectively). Furthermore, the total thoracoscopic double-valve replacement group experienced a shorter postoperative hospitalization time, averaging 6.21 ± 1.58 days, than the median sternotomy double-valve replacement group (8.35 ± 1.07 days, P < .001). The total thoracoscopic double-valve replacement group also exhibited significantly lower chest drainage volume (average 223.91 ± 53.93 mL) than the median sternotomy double-valve replacement group (382.56 ± 61.87 mL, P < .001). In terms of transfusion rates, the total thoracoscopic double-valve replacement group (9.21%) showed a marked reduction compared with the median sternotomy double-valve replacement group (36.36%, P < .001). Both groups had similar major complications.

Conclusions

The initial results of the total thoracoscopic double-valve replacement underscore its safety and efficacy. This approach extends the applicability of total thoracoscopic cardiac surgery and warrants deeper exploration.

Minimally invasive versus transcatheter closure of secundum atrial septal defects: a systematic review and meta-analysis

BACKGROUND

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to transcatheter (TC) closure of atrial septal defects (ASD). This systematic review and meta-analysis aims to compare post-operative outcomes of MIS versus TC repair in ASD closure.

METHODS

PubMed, Medline and EMBASE were searched from inception until June 2018 for randomised and observational studies comparing post-operative outcomes for MIS and TC repair. The studies were reviewed for bias using the ROBINS-I Score and pooled in a meta-analysis using STATA (version 15).

RESULTS

Six observational studies, involving 1524 patients assessing three primary and five secondary outcomes were included. Evidence suggests TC repair yielded shorter hospital stay (MD = 3.32, 95% CI 1.04-5.60) and lower rates of transient atrial fibrillation (AF) (RR = 0.48, 95% CI 0.20-1.15). TC repair patients also had fewer pericardial effusions (RR = 0.27, 95% CI 0.05-1.54, I² = 0.0%) and pneumothoraxes (RR = 0.18, 95% CI 0.04-0.80, I² = 0.0%). However, TC repair results in more minor residual shunts (RR = 6.04, 95% CI 1.69-21.63 in favour of MIS, I² = 39.0%). No differences were found for incidences of strokes (RR = 1.58, 95% CI 0.23-10.91, I² = 19.3%), unexpected bleeding (RR = 0.44, 95% CI 0.19-1.04, I² = 0.0%) and blood transfusion (RR = 0.39, 95% CI 0.09-1.59, I² = 0.0%).

CONCLUSIONS

MIS closure for ASD has similar outcomes compared to TC repair. However, the lack of randomised literature related to MIS versus TC repair for ASD closure warrants further evidence in the form of RCTs to further support these findings.

Intermediate-Term Outcomes of Totally Endoscopic Atrial Septal Defect Repair on Beating Heart in Small Children

Objective: Manipulation in a narrow surgical field and risks of femoral arterial (FA) complications are difficulties when applying totally endoscopic surgery (TES) for congenital heart disease in small children. This study was conducted to investigate the feasibility of TES for atrial septal defect (ASD) repair in children weighing 13 to 20 kg. Methods: From July 2016 to July 2021, 14 patients with a mean age of 5.4 ± 2.2 years and mean weight of 15.57 ± 2.39 kg (range, 13 to 20 kg), underwent TES for ASD repair on the beating heart. FA cannulation was established through a Dacron graft. An additional FA cannula (2 to 4 Fr smaller than the expected size) was placed into the left FA in case of increasing arterial pressure. Three 5 or 5.5 mm trocars and one 12 mm port were used. The surgical field was filled with CO₂. No aortic clamp, no aortic root needle, and no snaring of the inferior vena cava were used. The mean follow-up time was 37.9 ± 12.5 months. Results: Cardiopulmonary bypass (CPB) installation time, CPB time, and operation time were 42.6 ± 16.5 min, 113.1 ± 33.1 min, and 209.6 ± 50.6 min, respectively. Total drainage volume was 125.4 ± 89.2 mL. Patients did not need analgesics on day 4 or 5 after surgery. No severe complications, including arterial complications, were recorded during follow-up. Conclusions: By optimizing the surgical field and setting the FA cannula correctly, TES for ASD closure is feasible in small children weighing between 13 and 20 kg.

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.

Borrowing from Adult Cardiac Surgeons-Bringing Congenital Heart Surgery Up to Speed in the Minimally Invasive Era

The majority of congenital and adult cardiac surgery is performed through a median sternotomy. For surgeons, this incision provides excellent exposure; however, for patients, a median sternotomy confers a poorer cosmetic outcome and the possibility of postoperative respiratory dysfunction, chronic pain, and deep sternal wound infections. Despite the advances in adult cardiac surgery, the use of minimally invasive techniques in pediatric patients is largely limited to small case series and less complex repairs. In this article, we review the risks, benefits, and limitations of the minimally invasive congenital cardiac approaches being performed today. The interest in these approaches continues to grow as more data supporting reduced morbidity, decreased length of stay, and faster recovery are published. In the future, as the technology and surgical familiarity improve, these alternative approaches will become more common, and may someday become the standard of care.

Minimally invasive tricuspid valve surgery and concomitant MAZE procedure with closure of LA appendage through an ASD

Utilization of the ASD as a gateway to reach the left heart in tricuspid valve surgery may facilitate the use of a mini right thoracotomy and single atriotomy approach, avoiding the need for bi-atrial incisions and/or median sternotomy.

Bronchial blocker versus double-lumen endobronchial tube in minimally invasive cardiac surgery

BACKGROUND

To compare the therapeutic value of a bronchial blocker (BB) with a double-lumen tube (DLT) in minimally invasive cardiac surgery (MICS).

METHODS

Sixty patients who underwent MICS were randomized to use either a DLT (Group D, n = 30) or a BB (Group B, n = 29; one failed was omitted). The following data were collected: time of intubation and tube localization; incidence of tube displacement; postoperative sore throat and hoarseness; time of cardiopulmonary bypass; maintenance time for SpO₂ < 90% (PaCO₂ < 60 mmHg); mean arterial pressure and heart rate; SpO₂, PaO₂, PaCO₂, EtCO₂, mean airway pressure, and airway peak pressure; surgeons' satisfaction with anesthesia; and short-term complications.

RESULTS

The times of intubation and tube localization were significantly longer in Group B than in Group D (P < 0.05). Patients in Group B exhibited significantly lower incidence of tube displacement, postoperative sore throat, and hoarseness when compared with patients in Group D (P < 0.05). Mean arterial pressure and heart rate were significantly lower in Group B than in Group D after tracheal intubation (P < 0.05). The mean airway pressure and airway peak pressure were significantly lower in Group B than in Group D after one-lung ventilation (P < 0.05). SpO₂ and PaO₂ in Group B were significantly higher than in group D after cardiopulmonary bypass (P < 0.05). No short-term postoperative complications were observed in patients of Groups B and D during 3 month follow-up.

CONCLUSION

BB can be a potential alternative to the conventional DLT for lung isolation in MICS.

TRIAL REGISTRATION

ChiCTR1900024250, July 2, 2019.

Standard median sternotomy, right minithoracotomy, totally thoracoscopic surgery, percutaneous closure, and transthoracic closure for atrial septal defects in children: A protocol for a network meta-analysis

BACKGROUND

Atrial septal defect (ASD) is one of the most common congenital heart diseases, with an average of 1.64 per 1000 newborns with the ASD. Empirical studies suggest that surgery should be performed early in the presence of right atrium and or right ventricular enlargement, even for asymptomatic patients. Many surgical procedures can be used to treat ASD. But which method is the best choice remains unclear. This study aims to compare the efficacy and safety of standard median sternotomy, right minithoracotomy, totally thoracoscopic surgery, percutaneous closure, transcutaneous by echocardiography, and transcutaneous by radiotherapy for ASDs in children using Bayesian network meta-analysis (NMA).

METHODS

We will perform a comprehensive literature search using PubMed, EMBASE.com, the Cochrane Library, Web of Science, and Chinese Biomedical Literature Database to identify relevant studies from inception to April 2019. Randomized controlled trials, prospective or retrospective cohort studies that reported the efficacy and safety of surgical procedures for the treatment of atrial septal defects will be included. Risk of bias of the included randomized controlled trials and prospective or retrospective cohort studies will be evaluated according to the Cochrane Handbook 5.1.0 and the risk of bias in non-randomized studies of interventions, respectively. A Bayesian NMA will be performed using R 3.4.1.

RESULTS

The results of this NMA will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This NMA will summarize the direct and indirect evidence to assess the efficacy and safety of different surgical procedures for the treatment of ASDs.

ETHICS AND DISSEMINATION

Ethics approval and patient consent are not required as this study is a network meta-analysis based on published trials.

PROSPERO REGISTRATION NUMBER

CRD42019130902.

Three-port totally endoscopic repair vs conventional median sternotomy for atrial septal defect

PURPOSES

We assessed the validity of three-port totally endoscopic repair (3PTER) for atrial septal defect (ASD).

METHODS

Between February, 2000 and November, 2017, 151 patients underwent surgery for ASD. Forty-seven patients underwent 3PTER as minimally invasive cardiac surgery (MICS) and 104 patients underwent conventional median sternotomy (CMS). Propensity matching yielded 94 matched patients (47 vs 47). We compared the early results between the groups. The 3PTER technique was performed with the patient in the partial left lateral position, under cardio-pulmonary bypass (CPB) established through a groin incision. The three ports consisted of a main incision (3 cm), a trocar for the left-handed instrument, and a camera port in right antero-lateral chest.

RESULTS

MICS needed longer cross clamp and CPB times (57, 48-86 vs 24, 16-30 min, p < 0.01 and 115, 106-131 vs 53, 43-80 min, p < 0.01, respectively)*, although the operation time and hospital stay were significantly shorter (180, 159-203 vs 190, 161-225 min, p = 0.024 and 6.0, 6-8 vs 15, 13-19 days, p < 0.01, respectively)*. The intra-operative and postoperative bleeding were significantly less in MICS than CMS (20, 5-40 vs 225, 130-287.5 p < 0.01 and 200, 145-290 vs 340, 250-535 ml, p < 0.01, respectively)*. *: median, 25th-75th percentile.

CONCLUSION

Irrespective of the longer CPB and cross-clamp time than for CMS, MICS had a shorter operation time, less bleeding, and resulted in quicker recovery. The 3PTER was safe and cosmetically excellent.

Right mini-thoracotomy approach reduces hospital stay and transfusion of mitral or tricuspid valve reoperation with non-inferior efficacy: evidence from propensity-matched study

Background

There is limited evidence about the efficacy and cost difference between minimally invasive and conventional valve reoperation. This study intended to compare the short-term efficacy and cost between right mini-thoracotomy approach and median sternotomy approach in valve reoperation.

Methods

From Feb 2011 to Sep 2017, 156 patients underwent valve reoperation including 68 cases of minimally invasive approach and 88 cases of traditional median sternotomy approach in our hospital. A propensity scoring was used to match patients with similar demographic characteristics. A total of 42 pairs of patients were left and divided into the conventional sternotomy group (CS group) and the right mini-thoracotomy group (RT group). A retrospective study of efficacy and cost was conducted between two groups.

Results

There was no statistical difference between two groups in demographical characteristics after propensity-scoring match (P>0.05). In-hospital mortality was 11.9% (5/42) for CS group and 7.1% (3/42) for the RT group (P=0.687). No significant disparity was found in the incidence of complications between two groups (P>0.05). CPB time (P=0.012), bypass time (P=0.006) and operation time (P=0.003) of CS group were significantly higher than RT group. Blood loss (P=0.014) and transfusion volume (P=0.003) of RT group was less than CS group. Shorter ICU and hospital stay was seen in RT group compared with CS group (P<0.001). Though the materials cost of RT group was higher than CS group (P<0.001), no significant disparity was found in total cost between CS group and RT group (P=0.790).

Conclusions

The right mini-thoracotomy approach can achieve equivalent efficacy with conventional median approach, and doesn't necessarily increase the total cost. Moreover, the minimally invasive approach can decrease the operation time, hospital stay and blood product transfusion.

Clinical outcomes of a combined transcatheter and minimally invasive atrial septal defect repair program using a 'Heart Team' approach

Background

Contemporary transcatheter and minimally invasive approaches allow for improved cosmesis and eliminate sternotomy; however, access to a ‘Heart Team’ approach to minimally invasive atrial septal defect (ASD) repair remains limited in Canada.

Methods

Retrospective chart review of all minimally invasive atrial septal defect repairs performed between 2009 and 2017 at a quaternary cardiac care centre were included. We compared residual shunt, functional status, periprocedural complications, and hospital lengths-of-stay between patients undergoing transcatheter and minimally invasive endoscopic ASD repair.

Results

Between 2009 and 2017, 61 consecutive patients underwent ASD repair at a single centre: 28 patients underwent transcatheter closure (64.3% female; median age 57, interquartile range 43–70.5) and 33 patients underwent minimally invasive endoscopic repair (72.7% female; median age 37, interquartile range 24–50). Patient demographics were similar between the two groups with the exception of transcatheter patients having smaller defect size (1.65 cm versus 2.35 cm, p = 0.002). Procedural success was 93% (26/28) and 100% (33/33) for transcatheter and minimally invasive groups (p = 0.21), respectively. Periprocedural complications were similarly low between the two groups with the exception of longer hospital length-of-stay in the surgical patients (5 days vs 1 day, p < 0.0001). Over a follow-up period (transcatheter: 0.5–56.5 months, surgical: 0.25–89 months), there was no difference in residual shunt (14.3% versus 6.1%, p = 0.4) or NYHA I Functional Class (88.5% versus 96.9%, p = 0.21).

Conclusion

Transcatheter and minimally invasive approaches to ASD repair are safe and feasible in selected patients using a ‘Heart Team’ approach and represent attractive alternatives to median sternotomy.