Short-Term Clinical Results of Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Procedure.

Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of the isolated left anterior descending (LAD) artery or as a multi-vessel (MV) procedure for the diagonal branch (RD) or the left circumflex coronary artery (LCX) region. Methods: From 2021 to 2022, 91 patients underwent MIDCAB or multi-vessel MIDCAB procedures in our heart center. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending artery via the left minithoracotomy approach in all patients. Results: Of the patients, a total of 86.8% were male. Eighty percent of the patients had two- or three-vessel coronary artery disease. The mean age was 65.1 ± 10.1 years. The mean operation time was 2.6 ± 0.8 h. The 30-day mortality was 0. The mean required packed red blood cells (pRBC) was 0.4 ± 1.2 unit. The mean intensive care unit stay (ICU) was 1.5 ± 1.6 days. The mean follow-up time was 1.5 ± 0.5 years. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2.2%. The Kaplan-Meier survival rate was 98.8% at 1 and 2 years. Conclusions: The postoperative complication rate of our MIDCAB cohort is low, and the short-term survival is favorable. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible.

Femoral or Axillary Cannulation for Extracorporeal Circulation during Minimally Invasive Heart Valve Surgery (FAMI): Protocol for a Multi-Center Prospective Randomized Trial.

BACKGROUND: Minimally invasive heart valve surgery via anterolateral mini-thoracotomy with full endoscopic 3D visualization (MIS) has become the standard treatment of patients with valvular heart disease and low operative risk over the past two decades. It requires extracorporeal circulation and cardioplegic arrest. The most established form of arterial cannulation for MIS is through the femoral artery and is used by most surgeons, but it is suspected to increase the risk of stroke through retrograde blood flow. An alternative route of cannulation is the axillary artery, producing antegrade blood flow during extracorporeal circulation. METHODS: Femoral or axillary cannulation for extracorporeal circulation during minimally invasive heart valve surgery (FAMI) is a multicenter randomized controlled trial designed to determine whether axillary cannulation is superior to femoral cannulation for the outcome of a manifest stroke within 7 days postoperatively. The target sample size was 848 participants. Patients ≥ 18 years of age, with valvular regurgitation or stenosis scheduled for minimally invasive surgery via anterolateral mini-thoracotomy, were randomized to axillary cannulation (treatment group) or to femoral cannulation (standard care). Patients were followed up for seven days postoperatively. A CT scan was performed pre-operatively to screen patients for vascular calcifications and to assess the safety of femoral cannulation. The standard of care is femoral artery cannulation, but is performed only in patients without significant vascular calcifications or severe kinking of the iliac arteries and in patients with sufficient vessel diameter. The cannulation is performed via Seldinger's technique, and the vessel closed percutaneously using a plug-based vascular closure device. Only patients without significant vascular calcifications are considered for femoral cannulation, as an increased risk of stroke is assumed. In patients with vascular calcifications, axillary cannulation is the standard of care to avoid these risks. Retrospective studies have hinted that, even in patients without vascular calcifications, there may be a lower stroke risk with axillary cannulation compared to femoral cannulation. We present a protocol for a multi-center randomized trial to investigate this hypothesis. DISCUSSION: To date, evidence on the best access for peripheral artery cannulation during minimally invasive heart valve surgery has been scarce. Patients may benefit from axillary cannulation for extracorporeal circulation in terms of stroke risk and other neurological and vascular complications, though femoral cannulation is the gold standard. The aim of this study is to determine the risks of peri-operative stroke in a prospective randomized comparison of femoral vs. axillary cannulation.

Right minithoracotomy and resternotomy approach in patients undergoing a redo mitral valve procedure.

OBJECTIVES: A minimally invasive approach via a thoracotomy is an alternative in challenging redo cardiac procedures. Our goal was to present our early postoperative experience with minimally invasive cardiac surgery via a right minithoracotomy (minimally invasive) and resternotomy in patients undergoing a mitral valve procedure as a reoperation. METHODS: From 2017 until 2020, reoperation of the mitral valve was performed through a right-sided minithoracotomy in 27 patients and via a resternotomy in 26 patients. Patients with femoral vessels suitable for cannulation underwent a minimally invasive technique. Patients requiring concomitant procedures regarding the aortic valve were operated on via a resternotomy. RESULTS: The mean age was 66 ± 12 years in the minimally invasive group and 65 ± 12 years in the whole cohort. The average Society of Thoracic Surgeons score was 11 ± 10% in the minimally invasive group and 13 ± 9% in all patients. The majority of the patients underwent reoperation because of severe mitral valve insufficiency (48% and 55%, respectively). The mean time to reoperation was 7 ± 9 years (minimally invasive group). The 30-day mortality was 4% in the minimally invasive group and 11% in the whole cohort. The blood loss was 566 ± 359 ml in the minimally invasive group and 793 ± 410 ml totally. There were no postoperative neurological complications in the minimally invasive group and 1 (2%) in the whole cohort. Postoperative echocardiography revealed competent mitral valve/prosthesis function in all patients. CONCLUSIONS: A minimally invasive approach for a mitral valve reoperation in selected patients is a safe alternative to resternotomy with a low transfusion requirement. Both surgical techniques are associated with good postoperative outcomes.

Postoperative results of minimally invasive direct coronary artery bypass procedure in 234 patients.

Introduction: Minimally invasive approach in cardiac surgery has gained popularity. In order to reduce surgical trauma in coronary surgery minimally invasive direct coronary artery bypass (MIDCAB) has already been established. This technique has been introduced for revascularisation of isolated left anterior descending (LAD). It can also be performed for hybrid revascularisation procedure in multi-vessel disease. Methods: From 2017 to 2021, 234 patients received MIDCAB operation in our heartcenter 73% were male. Most of the patients had two or three vessel disease (74%). The average age of the patients was 66 ± 12 years mean. The left internal mammary artery (LIMA) was anastomosed to the LAD through left minithoracotomy approach. Multi-vessel MIDCAB (MV-MIDCAB) including two anastomoses (T-graft to LIMA with additional saphenous vein graft) was done in 15% (n = 35). Results: The average operation time was 2.3 ± 0.8 h mean. The 30-day mortality was 1.7% (n = 4). The average amount of packed red blood cells (pRBC) that was given intra- and postoperatively was 0.4 ± 0.8 units mean. The mean intensive care unit stay (ICU) was 1 ± 1.2 days. Three patients (1.3%) had wound infection postoperatively. The rate of neurologic complications was 0.4% (n = 1). Two patients (0.9%) had myocardial infarction and received coronary re-angiography perioperatively including stent implantation of the right coronary artery. Discussion: The MIDCAB procedure is a safe and less traumatic procedure for selected patients with proximal LAD lesions. It is also an option for hybrid procedure in multi-vessel disease. The ICU stay and application of pRBC's are low. Our MIDCAB results show a good postoperative clinical outcome. However, follow-up data are necessary to evaluate long-term outcome.