The Current State of Hybrid Coronary Revascularization

Hybrid coronary revascularization (HCR) combines a minimally invasive surgical approach with percutaneous coronary intervention (PCI) for the treatment of multi-vessel coronary artery disease. Despite decades of use, widespread acceptance has been limited. In this review, we conduct a comparative assessment of HCR in relation to traditional coronary artery bypass graft surgery and multi-vessel PCI. While large scale randomized data is still lacking, numerous studies have demonstrated that HCR may offer benefits regarding resource utilization and short-term morbidity, while delivering comparable mid- and long-term survival compared to traditional bypass surgery. Compared to PCI, HCR may offer similar peri-procedural morbidity, while mitigating the need for repeat revascularization by providing a surgical arterial bypass graft to the left anterior descending artery.

Percutaneous Versus Surgical Femoral Cannulation in Minimally Invasive Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

Minimally invasive cardiac surgery (MICS) is increasing worldwide. In most cases, the surgical technique includes cannulation of the groin for the establishment of cardiopulmonary bypass, requiring a second surgical incision (SC) for exposure and cannulation of the femoral vessels. With the introduction of arterial closure devices, percutaneous cannulation (PC) of the groin has become a possible alternative. We performed a meta-analysis and systematic review to compare clinical endpoints between the patients who underwent PC and SC for MICS.

METHODS

Three databases were assessed. The primary outcome was any access site complication. Secondary outcomes were perioperative mortality, any wound complication, any vascular complication, lymphatic complications, femoral/iliac stenosis, stroke, procedural duration, and hospital length of stay (LOS). A random effects model was performed.

RESULTS

A total of 5 studies with 2,038 patients were included. When compared with PC, patients who underwent SC showed a higher incidence of any access site complication (odds ratio [OR] = 3.09, 95% confidence interval [CI]: 1.87 to 5.10, P < 0.01), any wound complication (OR = 10.10, 95% CI: 3.31 to 30.85, P < 0.01), lymphatic complication (OR = 9.37, 95% CI: 2.15 to 40.81, P < 0.01), and longer procedural duration (standardized mean difference = 0.31, 95% CI: 0.12 to 0.51, P < 0.01). There was no significant difference between the 2 groups regarding perioperative mortality, any vascular complication, femoral/iliac stenosis, stroke, or hospital LOS.

CONCLUSIONS

The analysis suggests that surgical groin cannulation in MICS is associated with a higher incidence of any access site complication (especially wound complication and lymphatic fistula) and with a longer procedural time compared with PC. There was no difference in perioperative mortality.

Comparing clinical outcomes of hybrid coronary revascularization with open coronary artery bypass in patients with multi-vessels lesions

OBJECTIVES

Hybrid coronary revascularization (HCR) involves the use of minimally invasive direct coronary artery bypass grafting (CABG) to treat the left anterior descending artery (LAD), and percutaneous coronary intervention to treat non-LAD vessels. We reported the results of a comparative analysis between HCR and off-pump CABG via sternotomy (OPCABG).

METHODS

Data were retrospectively collated from patients who underwent HCR or OPCABG for multivessel coronary artery disease between 2011 and 2022. Propensity score-based matching was performed to reduce the selection bias. The Comparisons of cardiac-related death, major adverse cardiac and cerebrovascular events (MACCE), and repeat revascularization were performed by Kaplan-Meier analysis or the Fine-Gray test.

RESULTS

After matching, the baseline characteristics were well-balanced between the two groups with 91 patients per group. There was no significant difference in operative mortality rate (1.1% for HCR vs2.2% for OPCABG, p = 1.000). However, patients undergoing HCR required a significantly lower rate of blood product transfusions (p < .001) and experienced significantly fewer pulmonary complications than OPCABG patients (p < .001). At 10 years, the incidences of cardiac-related death, MACCE and repeat revascularization did not differ significantly between the two groups (9.5% vs11.5%, p = .277; 4.7% vs12.3%, p = .361; 1.2% vs2.5%, p = .914, respectively).

CONCLUSIONS

For patients with multi-vessel lesions, HCR was comparable to OPCABG in long-term outcomes such as cardiac-related death, MACCE, and the durability of grafts. Additionally, HCR was better than OPCABG in perioperative outcomes. HCR may be an alternative therapy for OPCABG in patients with multi-vessel coronary artery disease.

Transcatheter Edge-to-Edge Mitral Valve Repair versus Minimally Invasive Mitral Valve Surgery: An Observational Study

Background: Minimally invasive mitral valve surgery (MIC-MVS) has been established as preferred treatment of mitral regurgitation (MR), but mitral transcatheter edge-to-edge valve repair (M-TEER) is routinely performed in patients at high surgical risk and is increasingly performed in intermediate risk patients. Methods: From 2010 to 2021, we performed 723 M-TEER and 123 isolated MIC-MVS procedures. We applied a sensitivity analysis by matching age, left ventricular ejection fraction (LVEF), EuroSCORE II and etiology of MR. Results: Baseline characteristics showed significant differences in the overall cohort (p < 0.01): age 78.3 years vs. 61.5 years, EuroSCORE II 5.5% vs. 1.3% and LVEF 48.4% vs. 60.4% in M-TEER vs. MIC-MVS patients. Grade of MR at discharge was moderate/severe in 24.5% (171/697) in M-TEER vs. 6.5% (8/123) in MIC-MVS (p < 0.01). One-year survival was 91.5% (552/723) in M-TEER vs. 97.6% (95/123) in MIC-MVS (p = 0.04). A matching with 49 pairs (n = 98) showed comparable survival during follow-up, but a numerically higher mean mitral valve gradient of 4.1 mmHg (95% CI: 3.6-4.6) vs. 3.4 mmHg (95% CI: 3.0-3.8) in M-TEER (p = 0.04). Conclusions: Patients undergoing M-TEER had lower one-year survival than MIC-MVS, but differences disappeared after matching. Reduction in MR was less effective in M-TEER patients and postprocedural mitral valve gradients were higher.

Use of an Endobronchial Blocker in a Patient with Tracheobronchial Anomaly for Minimally Invasive Cardiac Surgery: A Case Report

Tracheal bronchi (TB) is a rare anomaly and is usually asymptomatic. Although it is generally not a problem when a single lumen tube is used, it may cause ventilation difficulties in the intraoperative period in procedures requiring one lung ventilation, such as minimally invasive cardiac surgery. Therefore, these difficulties may cause intraoperative and postoperative complications. While a double-lumen tube is recommended as the primary choice for one-lung ventilation in patients with TB, bronchial blockers can be used to avoid the need for tube exchange in patients who will remain intubated in the postoperative period.

Surgery of the ascending aorta via a right anterior minithoracotomy: initial surgical experience of a single center

OBJECTIVES

Full median sternotomy (FMS) is the common surgical access for patients undergoing replacement of the ascending aorta (AA) with or without aortic valve replacement (AVR). The right anterior mini-thoracotomy (RAMT) approach has been increasingly adopted for AVR. This approach has been shown to decrease blood loss and hospital length of stay (LOS) compared with FMS. The RAMT approach may also be beneficial in selected patients requiring AA procedures with or without AVR. We present our initial clinical experience of patients who have undergone a RAMT for supracommissural replacement of the tubular AA with or without AVR.

METHODS

This is a single-center retrospective review of 10 patients who underwent an elective RAMT for replacement of the tubular AA with or without AVR between November 2019 and January 2022. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital LOS, time to extubation, operative times, as well as postoperative complications such as stroke and bleeding.

RESULTS

Median cross-clamp and cardiopulmonary bypass times were 109 and 148 min, respectively. Median time to extubation was 2.5 h and median intensive care unit and hospital stay were 2 and 10 days, respectively. There were two re-thoracotomies for postoperative bleeding and two cases of sub-xiphoidal pericardial drainage for pericardial effusion. There were no strokes and no in-hospital nor 30-day mortalities.

CONCLUSIONS

The replacement of the AA with or without concomitant AVR can be performed through a RAMT in carefully selected patients. However, the safety of this approach, as compared to full/partial median sternotomy, remains to be proven.

Transcatheter aortic valve implantation versus sutureless aortic valve replacement: a single-centre cost analysis

AIMS

Sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve implantation (TAVI) are both viable therapeutic interventions for aortic stenosis in elderly patients. Meta-analyses show similar all-cause mortality for both techniques albeit with a different pattern of adverse effects. This study means to compare costs and, to a lesser extent, clinical outcomes of both techniques.

METHODS

A retrospective single-centre analysis was performed for patients receiving SU-AVR or TAVI from 2008 to 2019. Perioperative clinical data were collected from patient files. Costs were assessed by a cost allocation tool. In an attempt to avoid confounding, propensity score matching was carried out.

RESULTS

A total of 368 patients underwent either TAVI (n = 100) or SU-AVR (n = 268). After matching, there were 61 patients per treatment group. Length of stay was significantly longer in the SU-AVR group. Excluding device costs, total expenses for SU-AVR (median: €11,630) were significantly higher than TAVI (median: €9240). For both groups, these costs were mostly incurred on intensive care units, followed by nursing units. Non-medical staff was the largest contributor to expenses. Including device costs, SU-AVR (median: €14,683) was shown to be cost-saving compared to TAVI (median: €24,057).

CONCLUSIONS

To conclude, we found SU-AVR to be cost-saving compared to TAVI, largely due to higher device costs associated with the latter. Excluding device costs, TAVI was associated with lower expenses and shorter length of stay. Non-medical staff was the largest source of costs, suggesting length of stay to be a major financial determinant.

Minimally Invasive Pectus Excavatum Correction and Endoscopic Port Access Mitral Valve Surgery

This case study describes the successful short-term outcome of staged minimally invasive pectus excavatum correction and endoscopic mitral valve repair in a patient with severe mitral valve regurgitation and pectus excavatum.

Transcatheter Aortic Valve Replacement as a bridge to minimally invasive endoscopic mitral valve surgery in Elderly Patients in the era of ERAS and Fast Track TAVI concepts

In this bicentric study, we report the outcomes of combined transcatheter aortic valve replacement combined with minimally invasive mitral valve surgery. We included a cohort of six patients (79.6 ± 3.2 years, 83% women) with high-risk profiles and deemed to be non-operable with combined mitral and aortic valvular disease. All patients had unsuitable anatomies for transcatheter mitral valve edge-to-edge repair (TEER). Moreover, most of the patients (5/6) suffered a combined aortic valve lesion, which complicates the efficiency of cardioplegia in the case of CBP through minimally invasive incisions. The first stage was implanting a TAVI valve to achieve aortic valve competency and hence facilitate the infusion of cardioplegia after clamping the aorta during endoscopic mitral valve surgery. After one week, we performed the minimally invasive mitral valve repair. Most patients (n = 5; 83%) underwent successful endoscopic mitral valve repair. Intraoperatively, the mean ischemic time was 42 min, and the total bypass time was 72 min. Postoperatively, the mean intubation time was 0 h. Postoperative complications included reoperation for bleeding in one patient (16.7%) and a new heart block requiring pacemaker implantation in one patient (16.7%). There was neither in-hospital mortality nor 1-year mortality.

A rare and unique case: aortic valve replacement in a young adult with a stenotic unicommissural unicuspid aortic valve

Unicuspid aortic valve (UAV) is a rare congenital cardiac anomaly. There are two forms of UAV, including unicuspid acommissural and unicuspid unicommissural. Definitive management for UAV is surgical intervention, but due to the rarity of UAV, the long-term surgical outcomes as well as overall prognosis are not known. Here, we present the case of a 19-year-old patient who was found to have a UAV prenatally and underwent a mechanical aortic valve replacement through an upper hemi-sternotomy due to elevated aortic stenosis gradients and presence of symptoms.

The frail patient undergoing cardiac surgery: lessons learned and future perspectives

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

Totally endoscopic pulmonary valve replacement

A 68-year-old man with a history of valve-sparing aortic root replacement and endoscopic aortic valve replacement was admitted to our hospital with dyspnea. Transthoracic echocardiography revealed severe pulmonary valve regurgitation. The patient had undergone cardiac surgery twice, through median sternotomy and right thoracotomy; therefore, we planned endoscopic pulmonary valve replacement via the left thoracic approach. The patient was placed in a modified right lateral decubitus position and underwent mild hypothermic cardiopulmonary bypass. An on-pump beating-heart technique was used during surgery. The 3D endoscopic system and trocars for surgical instruments were inserted through the left 3rd and 4th intercostal spaces. After incision of the pulmonary artery, the pulmonary cusps were resected. A 27-mm St Jude Medical Epic heart valve was implanted in the intra-annular position. Subsequently, the left atrial appendage was resected. The patient was discharged without complications. To our knowledge, this is the first case of totally endoscopic pulmonary valve replacement.

Infective endocarditis associated with atopic dermatitis

Infective endocarditis caused by atopic dermatitis is common in young patients and has a high potential for causing embolism. Because of the high risk of mediastinitis postoperatively, minimally invasive cardiac surgery could be effective.

Robotic Resection of Left Atrial Myxoma With Cryoablation of Tumor Stalk

The purpose of this report is to demonstrate robotic cryoablation of an atrial myxoma stalk as a method to prevent recurrence and preserve atrial tissue. A 38-year-old female patient was taken to the operating room, and an atrial myxoma abutting the left inferior pulmonary vein was resected robotically. This was followed by cryoablation of the tumor stalk instead of a full-thickness resection to prevent an extensive reconstruction. The operation resulted in the successful resection of an atrial myxoma with minimal length of stay. Follow-up at 3 months has shown no evidence of residual or recurrent tumor. Follow-up at 1 year is planned. Cryoablation of an atrial myxoma stalk, when resection would require complex reconstruction, is a useful tool in the armamentarium of a minimally invasive cardiac surgeon.

A Rare Case of Rectus Muscle Twitching Due to Abandoned Uncapped Pacemaker Leads

Extra-cardiac stimulation after cardiac pacemaker implantation is seldom seen in the cardiac field. However, this case report demonstrates an unusual symptom of persistent abdominal twitching in a 42-year-old male patient who underwent pacemaker replacement, lasting for 15 years. Initially, it was attributed to diaphragmatic pacing by the new pacemaker. Despite several attempts to replace the endocardial leads, the patient's symptoms did not improve. Finally, he was referred to our hospital, where our team conducted further investigations and discovered that the old pacemaker lead was exposed, leading to excitation of the rectus muscle.

Aortic Valve Replacement: Understanding Predictors for the Optimal Ministernotomy Approach

INTRODUCTION

The most common minimally invasive approach for aortic valve replacement (AVR) is the partial upper mini-sternotomy. The aim of this study is to understand which preoperative computed tomography (CT) features are predictive of longer operations in terms of cardio-pulmonary bypass timesand cross-clamp times.

METHODS

From 2011 to 2022, we retrospectively selected 246 patients which underwent isolated AVR and had a preoperative ECG-gated CT scan. On these patients, we analysed the baseline anthropometric characteristics and the following CT scan parameters: aortic annular dimensions, valve calcium score, ascending aorta length, ascending aorta inclination and aorta-sternum distance.

RESULTS

We identified augmented body surface area (>1.9 m2), augmented annular diameter (>23 mm), high calcium score (>2500 Agatson score) and increased aorta-sternum distance (>30 mm) as independent predictors of elongated operation times (more than two-fold).

CONCLUSIONS

Identifying the preoperative predictive factors of longer operations can help surgeons select cases suitable for minimally invasive approaches, especially in a teaching context.

Re-expansion pulmonary edema after minimally invasive cardiac surgery in children

Re-expansion pulmonary edema is a serious complication that can occur after minimally invasive cardiac surgery through a right mini-thoracotomy. Herein, we describe two paediatric cases where re-expansion pulmonary edema was observed after simple atrial septal defect closure through a right mini-thoracotomy. This is the first case report of re-expansion pulmonary edema after a paediatric cardiac surgery.

Outcomes and residual gap analysis after the modified cryomaze procedure performed via right minithoracotomy versus sternotomy

Objectives

Developments in both technique and technology have enabled surgeons to perform the maze procedure via right minithoracotomy (RMT) to treat atrial fibrillation (AF). This study aimed to clarify the outcomes of the modified cryomaze procedure via the RMT approach compared with the sternotomy approach.

Methods

The study cohort comprised 803 consecutive patients who underwent a modified cryomaze procedure (130 via RMT and 673 via sternotomy) for paroxysmal AF and persistent AF from January 2001 to March 2022. The Gray test was applied to compare the incidence of recurrent atrial tachyarrhythmias. Additionally, residual electrical gaps were investigated in the patients who underwent additional catheter ablation for recurrent atrial tachyarrhythmias.

Results

The respective 1-, 2-, and 3-year cumulative incidences of recurrent atrial tachyarrhythmias were 13.1%, 19.5%, and 23.1% in the RMT group, and 9.3%, 10.9%, and 12.8% in the sternotomy group (Gray test P = .036). All 31 patients with recurrent atrial tachyarrhythmias underwent additional catheter ablation, comprising 14 (10.8%) in the RMT group and 17 (2.5%) in the sternotomy group. There was a significant intergroup difference in the site of residual electrical gaps; the RMT group more frequently had residual gaps in the tricuspid annulus than the sternotomy group (6.2% vs 0.4%; P < .001).

Conclusions

In the modified cryomaze procedure via the RMT approach, ablation failure is more likely to occur at the tricuspid annulus, where the surgical field of view is relatively poor compared with the sternotomy approach. Therefore, surgical ablation should be performed with caution when the RMT approach is used.

Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy

BACKGROUND

Avoidance of sternotomy while preserving complete revascularization remains challenging in multivessel coronary disease. Technical issues and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT) in nonselected patients with multivessel disease are reported.

METHODS

From November 2019 to September 2021, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed in 102 patients (92 males; 67 ± 10 [42-87] years). Slings were placed around ascending aorta, left pulmonary veins, and inferior vena cava for exposure of lateral and inferior ventricular wall. All patients had multivessel coronary disease (three-vessel disease: n = 72; two-vessel disease: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years, 14.7%), with severe left ventricular dysfunction (ejection fraction < 30%, 6.9%), massive obesity (body mass index > 35, 11.6%), and at increased risk (EuroSCORE II > 4, 15.7%).

RESULTS

Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting. A total of 323 distal anastomoses (3.2 ± 0.7 [2-5] per patient) were performed to revascularize left anterior descending (100%), circumflex (91.2%), and right coronary artery (67.7%). Complete revascularization was achieved in 95.1%. In-hospital mortality was 2.9%, stroke rate was 1.0%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 2.0%.

CONCLUSION

This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy. TCRAT can be introduced into clinical routine safely. Long-term results remain to be investigated.

Simple Tool for Bleeding Control During Minimally Invasive and Robotic Cardiac Surgery

Achievement of complete hemostasis is a key element to success in cardiac surgery. Bleeding control is of utmost importance in minimally invasive and robotic cardiac surgery to avoid conversion, as major bleeding is one of the most common indications for conversion to sternotomy. Bleeding control with surgical techniques can be technically more difficult in robotic and minimally invasive cardiac surgery as access to the bleeding area is limited and it is harder to intervene compared with open cardiac surgery with sternotomy. We present in this case the achievement of hemostasis in a minimally invasive robotic mitral repair, without the employment of surgical techniques and with the aid of a surgical sealant.

Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis.

Temporary venovenous extracorporeal membrane oxygenation after cardiopulmonary bypass in minimally invasive cardiac surgery via right minithoracotomy

OBJECTIVES

In minimally invasive cardiac surgery, it can be difficult at times to maintain adequate oxygenation with single-lung ventilation after weaning from cardiopulmonary bypass (CPB), and intermittent double-lung ventilation is required during hemostasis. Venovenous extracorporeal membrane oxygenation (VV-ECMO) after weaning from CPB eliminates the necessity of overinflation of the left lung and intermittent double-lung ventilation and enables secure and fast hemostasis. We investigated the effectiveness and safety of temporary VV-ECMO in MICS.

METHODS

Between May 2018 and March 2021, 149 patients underwent temporary VV-ECMO during minimally invasive cardiac surgery in our institutions. After weaning from CPB, the arterial circuit was reconnected to the right internal jugular venous cannula, the femoral venous cannula was pulled down by 20 cm, and VV-ECMO was established using the CPB machine and cannulas. After starting VV-ECMO, we administered protamine and performed hemostasis. Operative data and outcomes were retrospectively reviewed.

RESULTS

The mean VV-ECMO time and flow were 26 ± 13 minutes and 2.38 ± 0.40 L/m2, respectively. There was no thrombus in the CPB circuit, including the oxygenator. The trans-oxygenator pressure gradient index at the end of VV-ECMO significantly correlated with that at the start of VV-ECMO (r = 0.88; 95% CI, 0.79-0.94; P = .01). The 30-day mortality rate was 2.0%. The incidences of unilateral pulmonary edema, prolonged ventilation, and re-exploration for bleeding were 2.7%, 5.4%, and 2.0%, respectively.

CONCLUSIONS

Temporary VV-ECMO is safe and useful to maintain single-lung ventilation without overinflation after weaning from CPB for secure and fast hemostasis in minimally invasive cardiac surgery. No thrombotic event was found during temporary VV-ECMO without heparinization.

Left anterior minithoracotomy as a first-choice approach for isolated coronary artery bypass grafting and selective combined procedures

OBJECTIVES

Our goal was to describe the technique for and evaluate the results of the isolated coronary artery bypass grafting or combined grafting procedures with mitral valve repair/replacement and/or left ventricle aneurysm repair performed through a single left anterior minithoracotomy.

METHODS

Perioperative data of all patients who required isolated or combined coronary grafting from July 2017 to December 2021 were observed. The focus was on 560 patients who underwent isolated or combined multivessel coronary bypass using the "Total Coronary Revascularization via left Anterior Thoracotomy" technique. The main perioperative outcomes were analysed.

RESULTS

A left anterior minithoracotomy was used in 521 (97.7%) out of 533 patients who required isolated multivessel surgical coronary revascularization and in 39 (32.5%) out of 120 patients who required combined procedures. In 39 patients, multivessel grafting was combined with 25 mitral valve and 22 left ventricular procedures. Mitral valve repair was performed through the aneurysm (n = 8) or through the interatrial septum (n = 17). Perioperative outcomes in isolated and combined groups were next: aortic cross-clamp time-71.9 (SD: 19.9) and 120 (SD: 25.8) min; cardiopulmonary bypass time-145.7 (SD: 33.5) and 216 (SD: 45.8) min; total operating time-269 (SD: 51.8) and 324 (SD: 52.1) min; intensive care unit stay-2 (2-2) and 2 (2-2) days; total hospital stay-6 (5-7) and 6 (5-7) days; and total 30-day mortality was 0.54 and 0%, respectively.

CONCLUSIONS

A left anterior minithoracotomy can be effectively used as a first-choice approach to perform isolated multivessel coronary grafting and can be combined with mitral valve and/or left ventricular repair. Experience with isolated coronary grafting through an anterior minithoracotomy is required to achieve the satisfactory results in combined procedures.

Totally thoracoscopic surgical resection of left ventricular benign tumor

OBJECTIVE

The study objective was to explore the feasibility and safety of totally endoscopic resection of a left ventricular tumor through small chest incisions without robotic assistance.

METHODS

Four patients with a left ventricular tumor (1 papillary fibroelastoma, 1 lipoma, and 2 myxomas) underwent surgery with peripheral cardiopulmonary bypass. The mean age of patients was 58 ± 15 years. There were 3 female patients and 1 male patient. Through 3-port incisions in the right chest, pericardiotomy, bicaval cannulation, cardiac arrest, and atriotomy, left ventricular tumor resection was performed under thoracoscopy.

RESULTS

All patients had successful resections. The cardiopulmonary bypass and aortic crossclamp times were 110 ± 14 minutes and 58 ± 19 minutes, respectively. The length of stay in the intensive care unit was 38 ± 27 hours. There were no mortalities or complications in this cohort. Patients were discharged 7 days after the operation. Transthoracic echocardiography showed that the cardiac tumor was completely removed without any residue 3 months after surgery.

CONCLUSIONS

Totally endoscopic left ventricular tumor resection without a robotically assisted surgical system is feasible and reproducible. This technique could minimize surgical trauma and achieves complete tumor resection.

Comparative efficacy of serratus anterior plane block (SAPB) and fentanyl for postoperative pain management and stress response in patients undergoing minimally invasive cardiac surgery (MICS)

Background

Fast-tracking plays a significant role in reducing perioperative morbidity and postoperative hospital stay by facilitating early extubation and optimal pain control. Attenuating the stress response to surgery also has a crucial function in enhancing recovery. Serratus anterior plane block (SAPB) is a recently described technique for chest wall analgesia. More data is required to find out the effectiveness of analgesia by SAPB for minimally invasive cardiac surgery (MICS).

Aim

The study aimed to assess the efficacy and safety of ultrasound-guided SAPB compared to fentanyl for controlling post-thoracotomy pain and stress response in patients undergoing MICS.

Setting and Design

Time framed comparative, prospective, and observational study.

Materials and Methods

Patients undergoing MICS for coronary artery bypass grafting under general anesthesia were randomly assigned into two groups. SAPB group (Group A) patients were given 0.2% of 20 ml ropivacaine followed by catheter insertion for continuous infiltration at the end of the procedure. Fentanyl group (Group B) patients were given fentanyl infusion for postoperative analgesia. The primary outcome measured changes in visual analog scale (VAS) score (pain) and cortisol levels (for stress response) in both groups.

Results

VAS score was significantly low in Group A when compared to Group B (P < 0.0001). Cortisol levels were also lower in the SAPB group. Hemodynamic parameters (systolic blood pressure, diastolic blood pressure, pulse rate, and oxygen saturation) were more stable in Group A with a lesser requirement of top-up analgesics.

Conclusion

SAPB was more effective than fentanyl in managing post-thoracotomy pain after MICS. Cortisol level was lower in the group that received SAPB.

Midterm outcomes of isolated tricuspid valve surgery with a mini-thoracotomy and beating heart strategy

Background

Isolated tricuspid valve (TV) operation is considered high-risk surgery; thus, early surgical referral is frequently discouraged. Our study aims to evaluate the outcomes of isolated TV surgery with a mini-thoracotomy and beating heart strategy.

Methods

We retrospectively reviewed 25 patients [median age, 65.0 years (Q1-Q3, 59.0-72.0 years)] who had undergone mini-thoracotomy beating heart isolated TV surgery from January 2017 to May 2021. TV repair was performed in 16 patients (64.0%), and TV replacement in 9 patients (36.0%). Among them, 18 patients (72.0%) had previous cardiac surgery, including TV replacement (n=4, 16.0%) and TV repair (n=4, 16.0%).

Results

The median cardiopulmonary bypass time was 75.0 minutes (Q1-Q3, 61.0-98.0 minutes). There was 1 early mortality (4.0%) due to low cardiac output syndrome. Acute kidney injury requiring dialysis occurred in 3 patients (12.0%), and a permanent pacemaker was required in 1 patient (4.0%). The median lengths of stay in the intensive care unit and hospital were 1.0 day (Q1-Q3, 1.0-2.0) and 9.0 days (Q1-Q3, 6.0-18.0), respectively. The median follow-up duration was 30.3 months (Q1-Q3, 19.2-43.8). Freedoms from overall mortality, severe tricuspid regurgitation (TR), and significant tricuspid stenosis [i.e., trans-tricuspid pressure gradient (TTPG) ≥5 mmHg] at 4 years were 89.1%, 94.4%, and 83.3%, respectively. There was no TV reoperation.

Conclusions

Mini-thoracotomy beating heart strategy for isolated TV surgery showed favorable early and midterm outcomes. This strategy may be a valuable option for isolated TV operations.

Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial

BACKGROUND

Minimally invasive cardiac surgery provokes substantial pain and therefore analgesic consumption. The effect of fascial plane blocks on analgesic efficacy and overall patient satisfaction remains unclear. We therefore tested the primary hypothesis that fascial plane blocks improve overall benefit analgesia score (OBAS) during the initial 3 days after robotically assisted mitral valve repair. Secondarily, we tested the hypotheses that blocks reduce opioid consumption and improve respiratory mechanics.

METHODS

Adults scheduled for robotically assisted mitral valve repairs were randomised to combined pectoralis II and serratus anterior plane blocks or to routine analgesia. The blocks were ultrasound-guided and used a mixture of plain and liposomal bupivacaine. OBAS was measured daily on postoperative Days 1-3 and were analysed with linear mixed effects modelling. Opioid consumption was assessed with a simple linear regression model and respiratory mechanics with a linear mixed model.

RESULTS

As planned, we enrolled 194 patients, with 98 assigned to blocks and 96 to routine analgesic management. There was neither time-by-treatment interaction (P=0.67) nor treatment effect on total OBAS over postoperative Days 1-3 with a median difference of 0.08 (95% confidence interval [CI]: -0.50 to 0.67; P=0.69) and an estimated ratio of geometric means of 0.98 (95% CI: 0.85-1.13; P=0.75). There was no evidence of a treatment effect on cumulative opioid consumption or respiratory mechanics. Average pain scores on each postoperative day were similarly low in both groups.

CONCLUSIONS

Serratus anterior and pectoralis plane blocks did not improve postoperative analgesia, cumulative opioid consumption, or respiratory mechanics during the initial 3 days after robotically assisted mitral valve repair.

CLINICAL TRIAL REGISTRATION

NCT03743194.

Left ventricular pseudoaneurysm after endoscopic mitral valve repair for active endocarditis

A left ventricular pseudoaneurysm is a rare complication that can occur after infective endocarditis, possibly leading to serious complications such as cardiac tamponade, rupture, and recurrent infective endocarditis. We report a case of a totally-endoscopic repair of a pseudoaneurysm after endoscopic mitral valve repair. A 48-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis. A left ventricular pseudoaneurysm was found two weeks after the surgery. The pseudoaneurysm was repaired through a left thoracotomy with a totally endoscopic platform. The postoperative course was uneventful, and there was no recurrence at 18 months. Left ventricular pseudoaneurysm may be repaired with a left thoracotomy totally-endoscopic approach.

Right-Sided Minimally Invasive Direct Coronary Artery Bypass: Clinical Experience and Perspectives

Objective: Minimally invasive direct coronary artery bypass grafting (MIDCAB) using the left internal thoracic artery to the left descending artery is a clinical routine in the treatment of coronary artery disease. Far less is known on right-sided MIDCAB (r-MIDCAB) using the right internal thoracic artery (RITA) to the right coronary artery (RCA). We aimed to present our experience in patients with complex coronary artery disease who underwent r-MIDCAB. Materials and Methods: Between October 2019 and January 2023, 11 patients received r-MIDCAB using RITA to RCA bypass in a minimally invasive technique via right anterior minithoracotomy without using a cardiopulmonary bypass. Underlying coronary disease was complex right coronary artery stenosis (n = 7) and anomalous right coronary artery (ARCA; n = 4). All procedure-related and outcome data were evaluated prospectively. Results: Successful minimally invasive revascularization was achieved in all patients (n = 11). There were no conversions to sternotomy and no re-explorations for bleeding. Furthermore, no myocardial infarction, no strokes, and, most importantly, no deaths were observed. During the follow-up period (median 24 months), all patients were alive and 90% were completely angina free. Two patients received a repeated revascularization after surgery but independently from the RITA-RCA bypass, which was fully competent in both patients. Conclusion: Right-sided MIDCAB can be performed safely and effectively in patients with expected technically challenging percutaneous coronary intervention of the RCA and in patients with ARCA. Mid-term results showed high freedom from angina in nearly all patients. Further studies with larger patient cohorts and more evidence are needed to provide the best revascularization strategy for patients suffering from isolated complex RCA stenosis and ARCA.

Inward Displacement: A Novel Method of Regional Left Ventricular Functional Assessment for Left Ventriculoplasty Interventions in Heart Failure with Reduced Ejection Fraction (HFrEF)

BACKGROUND

Hybrid minimally invasive left ventricular reconstruction is used to treat patients with ischemic heart failure with reduced ejection fraction (HFrEF) and antero-apical scar. Pre- and post-procedural regional functional left ventricular assessment with current imaging techniques remains limited. We evaluated 'inward displacement' as a novel technique of assessing regional left ventricular function in an ischemic HFrEF population who underwent left ventricular reconstruction with the Revivent System.

METHODS

Inward displacement adopts three standard long-axis views obtained during cardiac MRI or CT and assesses the degree of inward endocardial wall motion towards the true left ventricular center of contraction. For each of the standard 17 left ventricular segments, regional inward displacement is measured in mm and expressed as a percentage of the maximal theoretical distance each segment can contract towards the centerline. The left ventricle was divided into three regions, obtaining the arithmetic average of inward displacement or speckle tracking echocardiographic strain at the left ventricular base (segments 1-6), mid-cavity (segments 7-12) and apex (segments 13-17). Inward displacement was measured using computed tomography or cardiac magnetic resonance imaging and compared pre- and post-procedurally in ischemic HFrEF patients who underwent left ventricular reconstruction with the Revivent System (n = 36). In a subset of patients who underwent baseline speckle tracking echocardiography, pre-procedural inward displacement was compared with left ventricular regional echocardiographic strain (n = 15).

RESULTS

Inward displacement of basal and mid-cavity left ventricular segments increased by 27% (p < 0.001) and 37% (p < 0.001), respectively, following left ventricular reconstruction. A significant overall decrease in both the left ventricular end systolic volume index and end diastolic volume index of 31% (p < 0.001) and 26% (p < 0.001), respectively, was detected, along with a 20% increase in left ventricular ejection fraction (p = 0.005). A significant correlation between inward displacement and speckle tracking echocardiographic strain was noted within the basal (R = -0.77, p < 0.001) and mid-cavity left ventricular segments (R = -0.65, p = 0.004), respectively. Inward displacement resulted in relatively larger measurement values compared to speckle tracking echocardiography, with a mean difference of absolute values of -3.33 and -7.41 for the left ventricular base and mid-cavity, respectively.

CONCLUSIONS

Obviating the limitations of echocardiography, inward displacement was found to highly correlate with speckle tracking echocardiographic strain to evaluate regional segmental left ventricular function. Significant improvements in basal and mid-cavity left ventricular contractility were demonstrated in ischemic HFrEF patients following left ventricular reconstruction of large antero-apical scars, consistent with the concept of reverse left ventricular remodeling at a distance. Inward displacement holds significant promise in the HFrEF population being evaluated pre- and post-left ventriculoplasty procedures.

Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia

OBJECTIVES

This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery.

DESIGN

A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery.

SETTING

This investigation was performed at a large quaternary referral center.

PARTICIPANTS

Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia.

INTERVENTIONS

Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block.

MEASUREMENTS AND MAIN RESULTS

One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group.

CONCLUSIONS

The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.

Thoracic paravertebral versus interpleural catheter for post-thoracotomy pain control in minimally invasive cardiac surgery

OBJECTIVE

The aim of this study was to compare efficacy and safety of paravertebral block (PVB) and interpleural analgesia (IPA) after minimally invasive cardiac surgery through thoracotomy in terms of quality of analgesia, post-operative mechanical ventilation time, intensive care unit (ICU) and hospital length of stay (LOS) and complications.

DESIGN

A randomized, prospective study.

PARTICIPANTS

A total of 50 adult patients (18-50 years old) undergoing minimally invasive cardiac surgery via thoracotomy.

INTERVENTION

Patients were randomized for group A: paravertebral epidural catheter (n = 25), group B: interpleural catheter (n = 25). All patients were given Inj. Bupivacaine 0.125%, 8 ml and Inj. Tramadol 100 mg as an adjuvant, total volume 10 ml.

RESULTS

After obtaining institutional review board approval, data collected and analysed - visual analogue score (VAS) at rest and on coughing, haemodynamic and respiratory parameters, time to extubation, supplementary analgesia requirement, LOS and complications. VAS was recorded at 0, 2, 3, 4, 8, 12 and 24 h post-extubation, while blood gases at-after shifting, 4, 8, 12 and 24 h. There were no significant differences in haemodynamic or respiratory parameters, VAS at rest and on coughing, ventilation duration, ICU and hospital LOS between two groups. The requirement of rescue analgesia was in one patient of mini coronary artery bypass in group B, while one patient in group A required reintubation due to respiratory acidosis and got successfully extubated on next day morning.

CONCLUSION

PVB and IPA both are safe and effective techniques for minimally invasive cardiac surgery with thoracotomy. It allows optimal pain control and safe ICU fast-track post-operative course.

A multi-module soft robotic arm with soft actuator for minimally invasive surgery

BACKGROUND

Compared to traditional rigid robotic arms, soft robotic arms are flexible, environmentally adaptable and biocompatible. Recently, most minimally invasive cardiac procedures still rely on traditional rigid surgical tools. However, rigid tools lack sufficient bending angles, which are high-risk in terms of contact with tissues and organs.

METHODS

A soft robotic arm with multiple degrees of freedom was designed to repair atrial septal defects in cardiac surgery. The developed multi-module soft robotic arm consists of four different units, including a bending unit, a turning unit, a stretching unit and gripper units. The three movement units can reach the specified position, and the gripper units can hold a surgical tool stably, such as a suture needle in cardiac surgery.

RESULTS

A cardiac surgery to repair an atrial septal defect has been completed, validating the reliability and functionality of the developed multi-module soft robotic arm.

CONCLUSIONS

The multi-module flexible soft robotic arm for minimally invasive surgery proposed in this paper can reach the designated surgical area during surgery to repair Atrial Septal Defects. Meanwhile, the design of the actuator of the robot arm was used a completely soft silicone material replacing the rigid material, which releases the contact trauma of the organs during the surgery.

The Clinical Application of Ultra-Fast-Track Cardiac Anesthesia in Right-Thoracoscopic Minimally Invasive Cardiac Surgery: A Retrospective Observational Study

OBJECTIVES

The purpose of this study was to investigate the effect of ultra-fast-track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery.

DESIGN

A retrospective observational study.

SETTING

A single large teaching hospital.

PARTICIPANTS

A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. The inclusion criteria were American Society of Anesthesiologists grade I to III, New York Heart Association (NYHA) cardiac function class I to III, and age ≥18 years. The exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (pulmonary arterial systolic pressure, PASP >70 mmHg), age ≤18 years or ≥80 years old, emergency surgery, and patients with incomplete or missing data.

INTERVENTIONS

Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received serratus anterior plane block-assisted ultra-fast- track cardiac anesthesia (UFTCA group), and 62 patients received conventional general anesthesia (CGA group). The primary outcomes were lengths of hospital stay and postoperative intensive care unit (ICU) stay. The secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications.

MEASUREMENTS AND MAIN RESULTS

The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25 ± 1.03 µg v 283.31 ± 11.36 µg, p < 0.001; and 1.94 ± 0.38 mg v 2.14 ± 0.99 mg, p < 0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group (10 patients [16.67%] v 30 patients [48.38%], p < 0.001). In the postoperative ICU, there were fewer patients with pain score Numeric Rating Scale ≥3 in the UFTCA group than that in the CGA group (10 patients [16.67%] v 29 patients [46.78%], p < 0.001). The postoperative extubation time in the UFTCA group was shorter than that in the CGA group (0.3 hours [range, 0.25-0.4 hours] v 13.84 hours [range, 10.25-18.36 hours], p < 0.001). Lengths of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group (27.73 ± 16.54 hours v 61.69 ± 32.48 hours, p < 0.001; and 8 days [range, 7-9] v 9 days [range, 8-12], p < 0.001, respectively). Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67 ± 13.05 mL v 318.23 ± 160.10 mL, p < 0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the 2 groups. The incidences of postoperative nausea, vomiting, or atelectasis were comparable between the 2 groups.

CONCLUSIONS

Serratus anterior plane block-assisted ultra-fast-track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.

Robot-Assisted Resection of Left Ventricular Papillary Fibroelastoma Arising From the Mitral Chordal Apparatus

The application of robot-assisted thoracoscopy to cardiac surgery affords an opportunity to leverage the exceptional intraoperative exposure, visualization, and dexterity of the robotic platform. Here, we report the case of a 72-year-old woman who presented to our institution for evaluation of a left ventricular mass that was identified following workup for an embolic event. We present an intraoperative video that provides technical details of the robot-assisted resection of the lesion, which was found to be a left ventricular papillary fibroelastoma arising from the mitral chordal apparatus. This case highlights the advantages provided by the robotic platform, which permitted complete, minimally invasive surgical excision of the lesion while minimizing the burden of surgical trauma.

Building a successful minimally invasive mitral valve repair program before introducing the robotic approach: The Massachusetts General Hospital experience

Background

Patients with mitral valve prolapse (MVP) requiring surgical repair (MVr) are increasingly operated using minimally invasive strategies. Skill acquisition may be facilitated by a dedicated MVr program. We present here our institutional experience in establishing minimally invasive MVr (starting in 2014), laying the foundation to introduce robotic MVr.

Methods

We reviewed all patients that had undergone MVr for MVP via sternotomy or mini-thoracotomy between January 2013 and December 2020 at our institution. In addition, all cases of robotic MVr between January 2021 and August 2022 were analyzed. Case complexity, repair techniques, and outcomes are presented for the conventional sternotomy, right mini-thoracotomy and robotic approaches. A subgroup analysis comparing only isolated MVr cases via sternotomy vs. right mini-thoracotomy was conducted using propensity score matching.

Results

Between 2013 and 2020, 799 patients were operated for native MVP at our institution, of which 761 (95.2%) received planned MVr (263 [34.6%] via mini-thoracotomy) and 38 (4.8%) received planned MV replacement. With increasing proportions of minimally invasive procedures (2014: 14.8%, 2020: 46.5%), we observed a continuous growth in overall institutional volume of MVP (n = 69 in 2013; n = 127 in 2020) and markedly improved institutional rates of successful MVr, with 95.4% in 2013 vs. 99.2% in 2020. Over this period, a higher complexity of cases were treated minimally-invasively and increased use of neochord implantation ± limited leaflet resection was observed. Patients operated minimally invasively had longer aortic cross-clamp times (94 vs. 88 min, p = 0.001) but shorter ventilation times (4.4 vs. 4.8 h, p = 0.002) and hospital stays (5 vs. 6 days, p < 0.001) than those operated via sternotomy, with no significant differences in other outcome variables. A total of 16 patients underwent robotically assisted MVr with successful repair in all cases.

Conclusion

A focused approach towards minimally invasive MVr has transformed the overall MVr strategy (incision; repair techniques) at our institution, leading to a growth in MVr volume and improved repair rates without significant complications. On this foundation, robotic MVr was first introduced at our institution in 2021 with excellent outcomes. This emphasizes the importance of building a competent team to perform these challenging operations, especially during the initial learning curve.

Safety and Efficacy of Right Axillary Thoracotomy for Repair of Congenital Heart Defects in Children

BACKGROUND

Minimally invasive repair of congenital heart defects in children has not gained wide popularity yet compared to minimally invasive approaches in adults. We sought to review our experience with this approach in children.

METHODS

This study included a total of 37 children (24 girls, 64.9%) with a mean age of 6.5 ± 5.1 years, who underwent vertical axillary right minithoracotomy for repair of a variety of congenital heart defects between May 2020 and June 2022.

RESULTS

The mean weight of these children was 25.66 ± 18.3 kg. Trisomy 21 syndrome was present in 3 patients (8.1%). The most common congenital heart defects that were repaired via this approach were atrial septal defects (secundum in 11 patients, 29.7%; primum in 5, 13.5%; and unroofed coronary sinus in 1, 2.7%). Twelve patients (32.4%) underwent repair of partial anomalous pulmonary venous connections with or without sinus venosus defects, while 4 patients (10.8%) underwent closure of membranous ventricular septal defects. Mitral valve repair, resection of cor triatriatum dexter, epicardial pacemaker placement, and myxoma resection occurred in 1 patient (2.7%) each. No early mortality or reoperations. All patients were extubated in the operating room, and the mean length of hospital stay was 3.3 ± 2.04 days. Follow-up was complete (mean 7 ± 5 months). No late mortality or reoperations. One patient required epicardial pacemaker placement due to sinus node dysfunction 5 months after surgery.

CONCLUSIONS

Vertical axillary right thoracotomy is a cosmetically superior approach that is safe and effective for repair of a variety of congenital heart defects in children.

A Systematic Review and Meta-Analysis of Robot-Assisted Mitral Valve Repair

OBJECTIVE

Robot-assisted surgery is a minimally invasive approach for repairing the mitral valve. This study aimed to assess its safety and clinical efficacy when compared with conventional sternotomy, partial sternotomy, and right minithoracotomy.

METHODS

A systematic review of peer-reviewed studies comparing robot-assisted mitral valve repair with conventional sternotomy, partial sternotomy, and right minithoracotomy was conducted following Cochrane Collaboration guidelines. Meta-analyses were performed where possible.

RESULTS

The search strategy yielded 15 primary studies, of which 12 compared robot-assisted with conventional sternotomy, 2 compared robot-assisted with partial sternotomy, and 6 compared robot-assisted with right minithoracotomy. The overall quality of evidence was low, and there was a lack of data on long-term outcomes. Individual studies and pooled data demonstrated that robotic procedures were comparable to conventional sternotomy and other minimally invasive approaches with respect to the rates of stroke, renal failure, reoperation for bleeding, and mortality. Robot-assisted mitral valve repair was superior to conventional sternotomy with reduced atrial fibrillation, intensive care unit and hospital stay, pain, time to return to normal activities, and physical functioning at 1 year. However, robot-assisted mitral valve repair had longer cardiopulmonary, aortic cross-clamp, and procedure times compared with all other surgical approaches.

CONCLUSIONS

Based on current evidence, robot-assisted mitral valve repair is comparable to other approaches for safety and early postoperative outcomes, despite being associated with longer operative times. Ideally, future studies will be randomized controlled trials that compare between robot-assisted surgery, conventional surgery, and other minimally surgery approaches focusing on hard clinical outcomes and patient-reported outcomes.

Comparison of minimally invasive versus conventional thoracic aortic operations: Early and midterm results in a series of 624 patients

OBJECTIVE

Despite minimally invasive techniques having gained wider application in cardiac surgery, current evidence on minithoracic aortic surgery is still limited. The aim of this study was to compare early and midterm outcomes of patients undergoing operations of the proximal thoracic aorta through ministernotomy (MS) versus full sternotomy (FS).

METHODS

Data from 624 consecutive patients who underwent proximal aortic repair through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at two aortic centers were analyzed. Treatment selection bias was addressed using propensity score matching (MS vs. FS). After matching, two well-balanced groups of 202 patients each were created.

RESULTS

Median cardiopulmonary bypass and cross-clamp times were 88 and 68 min, respectively, with no difference between groups. Overall, 30-day mortality was 1% (n = 2) in MS and 0.5% (n = 1) in FS (p = .6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4, 2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%). Patients receiving MS showed a lower incidence of respiratory insufficiency compared with FS (0% vs. 2.5%, p = .04). Intensive care unit and hospital stays were similar between groups. Two-year survival rate was 97.2% in MS and 96.5% in FS (p = .9).

CONCLUSIONS

Mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

Single-Center Experience With a Self-Expandable Venous Cannula During Minimally Invasive Cardiac Surgery

OBJECTIVE

Venous drainage is often problematic in minimally invasive cardiac surgery (MICS). Here, we describe our experience with a self-expandable stent cannula designed to optimize venous drainage.

METHODS

The smart canula^® was used in 58 consecutive patients undergoing MICS for mitral valve disease (n = 40), left atrial myxoma (n = 3), left ventricular outflow tract obstruction (n = 1), and aortic valve replacement via a right anterior minithoracotomy (n = 14) procedures. The venous cannula was placed under transesophageal echocardiography guidance to reach the superior vena cava. Vacuum-assisted venous drainage (between -20 and -35 mm Hg) was used to reach a target flow index of 2.2 L/min/m² at a core temperature of 34 °C using a goal-directed perfusion strategy aimed at a minimum DO₂ of 272 mL/min/m². Cardiopulmonary bypass (CPB) parameters were recorded, and hemolysis-related parameters were analyzed on postoperative days 1 to 7.

RESULTS

Mean body surface area and median body mass index were 1.9 ± 0.2 m² and 25.2 (23.4, 30.2) kg/m². Mean CPB and median cross-clamping times were 107.7 ± 24.4 min and 64.5 (53, 75.8) min, and median CPB flow during cardioplegic arrest was 4 (3.6, 4.2) L/min (median cardiac index 2.1 [2, 2.2] L/min/m²). Venous drainage was considered sufficient by the surgeon in all cases, and insertion and removal were uncomplicated. Mean SvO₂ during CPB was 80.2% ± 5.5%, and median peak lactate was 10 (8, 14) mg/dL, indicating sufficient perfusion. Mean venous negative drainage pressure during cross-clamping was 27.2 ± 12.3 mm Hg. Platelets dropped by 73.6 ± 37.5 K/µL, lactate dehydrogenase rose by 81.5 (44.3, 140.8) U/L, and leukocytes rose by 3.4 (2.2, 7.2) K/µL on postoperative day 1.

CONCLUSIONS

The venous smart canula^® allows for optimal venous drainage at low negative drainage pressures, facilitating sufficient perfusion in MICS.

Anterior Pathway for Epicardial Left Atrial Appendage Clip Occlusion During Minimally Invasive Atrioventricular Valve Surgery

The left atrial appendage occlusion (LAAO) by endocardial suture is sometimes inadequate and thrombogenic with uncertain electrical competence. Moreover, epicardial LAAO clip placement through the transverse sinus can be technically challenging during minimally invasive atrioventricular valve surgery. Here, we describe our new endoscopic technique via an anterior access pathway in 5 patients with concomitant atrial fibrillation using an epicardial clip device (AtriClip Pro 1 or AtriClip Pro 2, AtriCure, Mason, OH, USA) for LAAO. The LAAO was successful in all patients without residual perfusion and surgical complications. Epicardial LAAO by clip via the anterior access pathway represents a novel and feasible endoscopic technique for minimally invasive atrioventricular valve surgery.

Comprehensive characterization of the postoperative pericardial inflammatory response: Potential implications for clinical outcomes

Objective

There is a paucity of data on the inflammatory response that takes place in the pericardial space after cardiac surgery. This study provides a comprehensive assessment of the local postoperative inflammatory response.

Methods

Forty-three patients underwent cardiotomy, where native pericardial fluid was aspirated and compared with postoperative pericardial effluent collected at 4, 24, and 48 hours' postcardiopulmonary bypass. Flow cytometry was used to define the levels and proportions of specific immune cells. Samples were also probed for concentrations of inflammatory cytokines, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs).

Results

Preoperatively, the pericardial space mainly contains macrophages and T cells. However, the postsurgical pericardial space was populated predominately by neutrophils, which constituted almost 80% of immune cells present, and peaked at 24 hours. When surgical approaches were compared, minimally invasive surgery was associated with fewer neutrophils in the pericardial space at 4 hours' postsurgery. Analysis of the intrapericardial concentrations of inflammatory mediators showed interleukin-6, MMP-9, and TIMP-1 to be highest postsurgery. Over time, MMP-9 concentrations decreased significantly, whereas TIMP-1 levels increased, resulting in a significant reduction of the ratio of MMP:TIMP after surgery, suggesting that active inflammatory processes may influence extracellular matrix remodeling.

Conclusions

These results show that cardiac surgery elicits profound alterations in the immune cell profile in the pericardial space. Defining the cellular and molecular mediators that drive pericardial-specific postoperative inflammatory processes may allow for targeted therapies to reduce immune-mediated complications.

Redo Aortic Valve Replacement With Perceval Prosthesis via Minithoracotomy in a Patient With Permanent Tracheostoma and Tracheoesophageal Shunt

A 76-year-old male patient had undergone aortic valve replacement with a 19-mm Carpentier-Edwards Perimount valve 12 years prior and underwent laryngopharyngo-esophagectomy for hypopharyngeal carcinoma followed by permanent tracheostomy and tracheoesophageal shunt creation 2 years later. Echocardiography showed exacerbated structural valve deterioration of the bioprosthesis, necessitating redo surgery. A permanent tracheostoma, located just above the upper edge of the sternum, seemed to be at high risk of serious infections when median resternotomy was performed. To minimize the risk of infection, we performed implantation of a Perceval prosthesis via the right anterior minithoracotomy after sufficient anatomical assessments. There was no evidence of mediastinitis or wound infection during the follow-up period. This report highlights that the less invasive Perceval implantation strategically allowed reduction in the resternotomy-associated infection risks in this patient.

Simplifying Mitral Valve Repair: A Guide to Neochordae Reconstruction

Mitral valve reconstruction techniques using polytetrafluoroethylene sutures are associated with high repair rates and excellent durability but are dependent on accurate neochordae length estimates. Current strategies to determine the appropriate length of artificial neochordae commonly rely on nonphysiologic saline testing on the arrested heart, with erroneous lengths resulting in residual mitral regurgitation. We present a guide for reproducible and accurate neochordae reconstruction based upon transesophageal echocardiographic measurements, which simplifies mitral repair for most patients with degenerative mitral regurgitation and can be used in conventional or minimally invasive approaches.

Cost Analysis of Endoscopic Conduit Harvesting Technique Using a Non-Sealed System for Coronary Artery Bypass Surgery

Objective: Endoscopic vessel harvest (EVH) is evolving as the standard of care for coronary artery bypass grafting. However, the increase in upfront equipment-related costs has resulted in reluctance of uptake globally. We investigated the costs involving a non-sealed technique for EVH versus open vessel harvesting techniques (OVH) for both the greater saphenous vein and radial artery with a 6-month follow-up. Methods: From September 2016 to December 2018, 226 patients underwent OVH while 251 patients underwent EVH using a reusable non-sealed system and a single-use radiofrequency sealing system. Cumulative costs for OVH versus EVH were calculated as a summation of total operative and in-hospital stay costs. Costs related to harvest site complication management were also analyzed for up to 6 months. Results: Total operative costs were greater in the EVH group (Can$2,283.70 [Can$1,377.60 to $4,183.50] vs Can$1,742.40 [Can$998.50 to $3,628.10], P < 0.001). Total length of stay was significantly shorter for the EVH group (5.9 [4 to 43] days vs 6.8 [4 to 55] days, P = 0.018). Cumulative costs were comparable at the end of the hospitalization period (EVH, Can$6,534.70 [Can$2,076.50 to $33,087.70] vs OVH, Can$6,112.50 [Can$3,322.30 to $45,503.50], P = 0.06). After discharge, harvest site-related complications occurred more frequently in the OVH group (27% vs 4.4%, P < 0.001), resulting in increased use of antibiotics (2.2% vs 0.8%, P = 0.02) as well as more frequent requirement for home nursing assistance in the OVH group (5.7% vs 0.8%, P = 0.002) at 6 months of follow-up. Conclusions: Cumulative costs did not show a statistical difference between OVH and EVH, with higher intraoperative costs for EVH being offset by higher harvest site management costs in the OVH group.

Innovative use of biotrace tempo pacemaker lead following cardiac surgery

The Tempo® Temporary Pacing Lead is a temporary, transvenous, active fixation pacemaker lead used exclusively in structural heart and electrophysiology procedures since regulatory approval in 2016. We utilized the Tempo lead for four patients undergoing redo-robotic cardiac surgery in which surgical epicardial leads could not be placed. No failure-to-pace events were encountered and patients were able to participate in various levels of physical activity without limitation.

Periareolar approach in female patients undergoing mitral and tricuspid valve surgery: An almost invisible surgical access

BACKGROUND AND AIM OF THE STUDY

Periareolar minithoracotomy represents an interesting option in minimally invasive cardiac surgery and it is our preferred approach for women. Our aim is to assess the results in female patients, in terms of nipple postoperative pain, local sensitivity, and eventual alterations in mammography after surgery.

METHODS

Fifty-seven female patients underwent periareolar incision, as minithoracotomy approach, from December 2018 to December 2021. Their mean age was 56 ± 12 years, their body mass index was 22.5 ± 4.8; their surgery was elective in 93%, with mean Euroscore II about 2 ± 1.3.

RESULTS

Of 57 patients, 87.7% (50 patients) underwent mitral valve repair, whose six with associated procedures; 8.8% (five patients) underwent mitral valve replacement whose two with tricuspid annuloplasty associated and 3.5% (two patients) had isolated tricuspid surgery. The cardiopulmonary bypass and aortic cross-clamp time were 123.2 ± 30.2 and 101.3 ± min respectively. There were no conversions to either full sternotomy or larger thoracotomy approach. There were no in-hospital and follow-up deaths. No strokes or wound infections were observed. Mean follow-up was 16± 9 months. Within the investigated follow-up, 100% of the patients were satisfied with the esthetic result, no remarkable postoperative pain was reported, two patients had slight hyposensitivity in the nipple area. About 50% IThad mammography as prevention screening after surgery and no abnormalities were found.

CONCLUSIONS

Periareolar minithoracotomy is a feasible surgical option in female patients, with excellent healing and cosmetic results and preserving the tissues of the mammary gland.