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Background: Right anterior mini thoracotomy (RAMT) for aortic valve replacement (AVR) is a minimally invasive procedure that avoids sternotomy. Herein, we report the outcomes of patients who underwent redo-cardiac via a RAMT approach for AVR. Methods: This case series reports the clinical outcomes of 14 consecutive redo operations, done in Calgary (Canada) and Gdansk (Poland) between 2020 and 2023. Primary outcomes were 30-day mortality and disabling stroke. Secondary outcomes included surgical times, hemodynamics, permanent pacemaker implantation (PPM), length of ICU and hospital stay, new post-operative atrial fibrillation (POAF), post-operative blood transfusion, incidence of acute respiratory distress syndrome (ARDS), rate of continuous renal replacement therapy (CRRT) and/or dialysis, and chest tube output in the first 12-hours after surgery. Results: Nine patients were male, and the mean age was 64.36 years. There were no deaths, while one patient had a disabling stroke postoperatively. Mean cardiopulmonary bypass and cross clamp-times were 136â min and 90â min, respectively. Three patients needed a PPM, 3 patients needed blood transfusions, and 2 developed new onset POAF. Median lengths of ICU and hospital stays were 2 and 12 days, respectively. There was no incidence of paravalvular leak greater than trace and the average transvalvular mean gradient was 12.23â mmHg. Conclusion: The number of patients requiring redo-AVR is increasing. Redo-sternotomy may not be feasible for many patients. This study suggests that the RAMT approach is a safe alternative to redo-sternotomy for patients that require an AVR.
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RASopathies cause nonsarcomeric hypertrophic cardiomyopathy via dysregulated signaling through RAS and upregulated mitogen-activated protein kinase activity. We provide the first report of the successful treatment of an adult with RAF1-associated hypertrophic cardiomyopathy using trametinib, a MEK inhibitor.
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PURPOSE OF REVIEW: Patients with advanced age and frailty require interventions for structural heart disease at an increasing rate. These patients typically experience higher rates of postoperative morbidity, mortality and prolonged hospital length of stay, loss of independence as well as associated increased costs to the healthcare system. Therefore, it is becoming critically important to raise awareness and develop strategies to improve clinical outcomes in the contemporary, high-risk patient population undergoing cardiacprocedures. RECENT FINDINGS: Percutaneous options for structural heart disease have dramatically improved the therapeutic options for some older, frail, high-risk patients; however, others may still require cardiac surgery. Minimally invasive techniques can reduce some of the physiologic burden experienced by patients undergoing surgery and improve recovery. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) is a comprehensive, interdisciplinary, evidence-based approach to perioperative care. It has been shown to improve recovery and patient satisfaction while reducing complications and length of stay. SUMMARY: Combining minimally invasive cardiac surgery with enhanced recovery protocols may result in improved patient outcomes for a patient population at high risk of morbidity and mortality following cardiac surgery.
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Recuperação Pós-Cirúrgica Melhorada , Procedimentos Cirúrgicos Minimamente Invasivos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Doenças das Valvas Cardíacas/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Assistência Perioperatória/métodosRESUMO
OBJECTIVE: The surgical treatment of aortic stenosis continues to evolve, and sutureless aortic valve replacement (SUAVR) is an emerging technology. With the Perceval S (Corcym, London, UK) as the only true sutureless valve on the market, the objective of this review is to analyze the current literature on Perceval S. Focusing on valve design and deployment as well as applications of the technology for challenging pathology, clinical outcomes are assessed, including a comparison with transcatheter AVR (TAVR). METHODS: PubMed and MEDLINE were searched by 3 authors for studies analyzing SUAVR from inception to May 19, 2023. RESULTS: SUAVR facilitates minimally invasive surgery and offers an alternative strategy for patients with small aortic annuli. It also has a time-saving advantage for patients who require complex operations. SUAVR results in excellent long-term morbidity, mortality, durability, and hemodynamic function. In comparison with conventional surgical AVR (SAVR), SUAVR does have a greater risk of postoperative pacemaker implantation; however, increasing user experience and refinements in implantation technique have contributed to reductions in this outcome. SUAVR results in morbidity and mortality that is similar to rapid-deployment AVR. Midterm outcomes are superior to TAVR; however, further robust investigation into all of these comparisons is ultimately necessary. CONCLUSIONS: SUAVR bridges the gap in technology between SAVR and TAVR. The application of this exciting technology will undoubtedly grow in the coming years, during which additional investigation is paramount to optimize preoperative planning, valve deployment, and reintervention strategies.
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Estenose da Valva Aórtica , Valva Aórtica , Bioprótese , Próteses Valvulares Cardíacas , Procedimentos Cirúrgicos sem Sutura , Substituição da Valva Aórtica Transcateter , Humanos , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Procedimentos Cirúrgicos sem Sutura/métodos , Substituição da Valva Aórtica Transcateter/métodos , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/instrumentação , Desenho de Prótese , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Resultado do TratamentoAssuntos
Insuficiência Cardíaca , Coração Auxiliar , Disfunção Ventricular Esquerda , Disfunção Ventricular Direita , Humanos , Citrato de Sildenafila/uso terapêutico , Coração Auxiliar/efeitos adversos , Estudos de Viabilidade , Insuficiência Cardíaca/prevenção & controle , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Background: The NeoChord DS1000 system implants artificial neochords transapically, through a left mini-thoracotomy to treat degenerative mitral valve regurgitation (MR). Performed without cardiopulmonary bypass, neochord implantation and length adjustment is guided by transesophageal echocardiography. We describe imaging and clinical outcomes for a single center case series using this innovative device platform. Methods: In this prospective series, all study patients had degenerative MR and were considered for conventional mitral valve surgery. Moderate to high-risk candidates were screened for NeoChord DS1000 eligibility based on echocardiographic criteria. Study criteria included isolated posterior leaflet prolapse, leaflet-to-annulus index greater than 1.2, and coaptation length index greater than 5â mm. Patients with bileaflet prolapse, mitral annular calcification, and ischemic MR were excluded from our early experience. Results: Ten patients underwent the procedure, including 6 males and 4 females, with a mean age of 76 ± 9.5 years. All patients had severe chronic MR and normal left ventricular function. One patient required conversion to an open procedure for failure to deploy neochords with the device transapically. The median number of NeoChord sets was 3 (IQR 2.3-3.8). Immediate post-procedure (POD#0) degree of MR on echocardiography ranged from mild or less, and on postoperative day 1 (POD#1) from moderate or less. Average length of coaptation was 0.85 ± 0.21â cm and average depth of coaptation was 0.72 ± 0.15â cm. At 1-month follow-up echocardiography, MR was graded from trivial to moderate and left ventricular inner diameter dimensions decreased from an average of 5.4 ± 0.4â cm to 4.6 ± 0.3â cm. None of the patients who had successful NeoChord implantation required blood products. There was 1 perioperative stroke with no residual deficits. There were no device-related complications or serious adverse events. The median length of hospital stay was 3 (IQR 2.3-10) days. 30-day and 6-weeks postoperative mortality and readmission rates were 0%. Conclusion: We report the first Canadian case series using the NeoChord DS1000 system for off-pump, transapical, beating heart mitral valve repair, through a left mini-thoracotomy. The early surgical outcomes suggest this approach is feasible, safe, and effective in reducing MR. This novel procedure has the advantage of offering a minimally invasive, off-pump option for select patients with high surgical risk.
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Objectives: Cardiac surgery using cardiopulmonary bypass contributes to a robust systemic inflammatory process. Local intrapericardial postsurgical inflammation is believed to trigger important clinical implications, such as postoperative atrial fibrillation and postsurgical intrathoracic adhesions. Immune mediators in the pericardial space may underlie such complications. Methods: In this prospective pilot clinical study, 12 patients undergoing isolated coronary artery bypass graft surgery were enrolled. Native pericardial fluid and venous blood samples (baseline) were collected immediately after pericardiotomy. Postoperative pericardial fluid and venous blood samples were collected 48-hours after cardiopulmonary bypass and compared with baseline. Flow cytometry determined proportions of specific immune cells, whereas multiplex analysis probed for inflammatory mediators. Results: Neutrophils are the predominant cells in both the pericardial space and peripheral blood postoperatively. There are significantly more CD163lo macrophages in blood compared with pericardial effluent after surgery. Although there are significantly more CD163hi macrophages in native pericardial fluid compared with baseline blood, after surgery there are significantly fewer of these cells present in the pericardial space compared with blood. Postoperatively, concentration of interleukin receptor antagonist 6, and interleukin 8 were significantly higher in the pericardial space compared with blood. After surgery, compared with blood, the pericardial space has a significantly higher concentration of matrix metalloproteinase 3, matrix metalloproteinase 8, and matrix metalloproteinase 9. The same trend was observed with transformational growth factor ß. Conclusions: Cardiac surgery elicits an inflammatory response in the pericardial space, which differs from systemic inflammatory responses. Future work should determine whether or not this distinct local inflammatory response contributes to postsurgical complications and could be modified to influence clinical outcomes.
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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.
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Procedimentos Cirúrgicos Cardíacos , Insuficiência da Valva Mitral , Robótica , Humanos , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Esternotomia/métodos , Resultado do Tratamento , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos RetrospectivosRESUMO
Sternal reentry when the ascending aorta is adherent to the posterior table of the sternum is associated with substantial risk. A minimally invasive right thoracotomy beating heart approach is an alternative when the aorta cannot be cross-clamped. This report details this technique for a complex reoperative mitral valve repair procedure performed in a patient with connective tissue disease who had required multiple aortic operations and presented with heart failure and severe functional mitral regurgitation.
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Procedimentos Cirúrgicos Cardíacos , Doenças do Tecido Conjuntivo , Implante de Prótese de Valva Cardíaca , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Esternotomia/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Toracotomia/métodos , Reoperação , Doenças do Tecido Conjuntivo/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodosRESUMO
Background: Left ventricular assist devices (LVADs) improve survival and quality of life, as either destination therapy or a bridge to transplantation. Although less-invasive hemisternotomy approaches for LVAD implantation are well studied, only a paucity of data is available in the literature on sternum-sparing bilateral minithoracotomy (BMT). Our centre has one of Canada's most extensive experiences with the BMT approach. Herein, we compared LVAD implantation via BMT with patients who received full median sternotomy or hemisternotomy. Methods: A single-centre retrospective review of data from Foothills Medical Centre (Calgary, Canada) was performed. Patients underwent LVAD insertion from 2012 to 2019, receiving either BMT (n = 11) or sternotomy (full median sternotomy or upper hemisternotomy with left minithoracotomy; n = 38). Intraoperative and early postoperative outcomes were assessed. Results: Patients who received BMT had significantly fewer transfusions of red blood cells, fresh frozen plasma, and platelets. The BMT group had lower chest-tube output in the first 12 hours. No significant differences occurred in ventilation time, intensive care unit length of stay, mortality, stroke, or reoperation for bleeding. Conclusions: Outcomes suggest that sternum-sparing LVAD implantation is a feasible alternative to sternotomy, leading to less postoperative blood loss and transfusion in the early postoperative period. Less transfusion is particularly valuable in this patient population, to reduce antigen-related sensitization prior to transplantation. Additional study is needed to assess potential benefits related to right heart function, postoperative mobility, and re-entry for transplantation.
Introduction: Les dispositifs d'assistance ventriculaire gauche (DAVG) contribuent à améliorer la survie et la qualité de vie, soit en traitement définitif ou en attente d'une transplantation. Bien que des approches d'hémisternotomie moins invasives lors de l'implantation d'un DAVG font l'objet d'un bon nombre d'études, seules de rares données sont disponibles dans la littérature sur la minithoracotomie bilatérale (MTB) sans ouverture du sternum. Notre centre possède l'une des expériences les plus approfondies au Canada de l'approche par MTB. Dans le présent article, nous avons comparé l'implantation du DAVG par MTB chez les patients qui avaient subi une sternotomie médiane complète ou une hémisternotomie. Méthodes: Nous avons réalisé une revue rétrospective unicentrique des données du Foothills Medical Centre (Calgary, Canada). Les patients avaient subi l'insertion d'un DAVG de 2012 à 2019, soit par MTB (n = 11) ou par sternotomie (sternotomie médiane complète ou hémisternotomie supérieure associée à une minithoracotomie gauche ; n = 38). Nous avons évalué les résultats peropératoires et postopératoires précoces. Résultats: Les patients qui avaient subi une MTB avaient eu significativement moins de transfusions de globules rouges, de plasma frais congelé et de plaquettes. Le groupe de MTB avait un plus faible débit du drain thoracique dans les 12 premières heures. Aucune différence significative dans la durée de ventilation, la durée du séjour aux soins intensifs, la mortalité, l'accident vasculaire cérébral ou la réopération en raison d'un saignement n'a été observée. Conclusions: Les résultats montrent que l'implantation de DAVG sans ouverture du sternum est une alternative à la sternotomie, qui entraîne moins de pertes de sang postopératoires et de transfusions en phase postopératoire précoce. Un moins grand nombre de transfusions est particulièrement important au sein de cette population de patients afin de réduire la sensibilisation aux antigènes avant la transplantation. D'autres études sont nécessaires pour évaluer les avantages potentiels liés à la fonction du cÅur droit, la mobilité après l'opération et la réadmission pour une transplantation.
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Mitral annular calcification (MAC) is a degenerative process that can cause mitral valve stenosis. Conventional surgical mitral valve replacement (MVR) for MAC with mitral stenosis can be challenging and associated with significant risk. Open surgical MVR with a transcatheter valve can offer an alternative in select situations. When such a strategy is not feasible, a beating-heart, mini-thoracotomy MVR with a SAPIEN 3 transcatheter heart valve can be considered. The novel teaching point of this case is use of an alternative approach for managing severe mitral stenosis secondary to MAC, when conventional surgical and transcatheter strategies are not safe or possible.
La calcification de l'anneau mitral (CAM) est un processus dégénératif qui peut causer la sténose mitrale. Le remplacement valvulaire mitral (RVM) par intervention chirurgicale traditionnelle lors de CAM associée à la sténose mitrale peut être complexe et est associé à un risque important. Le RVM à cÅur ouvert par cathéter peut être une solution dans certaines situations. Lorsque cette stratégie n'est pas faisable, le RVM à cÅur battant par mini-thoracotomie à l'aide d'une valve cardiaque SAPIEN 3 par cathéter peut être envisagé. Le nouveau point à retenir de ce cas est l'utilisation d'une autre approche pour prendre en charge la sténose mitrale grave secondaire à la CAM, lorsque les stratégies d'intervention chirurgicale traditionnelle et de cathétérisme ne sont pas sûres ou possibles.
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Primary tumors of the heart are rare where nearly half of the benign cardiac masses are myxomas. Clinical features of myxoma are determined by their location, size, and mobility. Most patients present with one or more of the triad of embolism, intracardiac obstruction, and constitutional symptoms. Herein, we present the case of a 60-year-old female with a history of genital prolapse who had new onset worsening dyspnea two days after an elective total abdominal hysterectomy, bilateral salpingo-oopherectomy, and vaginal repair. She was initially thought to have a pulmonary embolism so had a computed tomography scan that revealed a cardiac mass, which was diagnosed to be a myxoma. Although rare, atrial myxomas can present in any patient population. This case report is educational as it highlights the atypical presentation of an atrial myxoma. To facilitate appropriate management, high degree of suspicion should be complemented with a comprehensive physical examination and set of investigations.
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The surgical management of aortic valve endocarditis can be challenging. Infection with abscess formation can destroy the root and annulus, making it difficult to anchor a valve conduit. In this article, we present a novel and efficient strategy for proximal aortic reconstruction. We used a Dacron tube graft and anchored it proximally with a running suture line deep in the left ventricular outflow tract. The coronary buttons were attached, and a Perceval valve was then deployed inside the neo-root to create a bio-Bentall.
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Endocardite Bacteriana , Endocardite , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Procedimentos de Cirurgia Plástica , Valva Aórtica/cirurgia , Catéteres , Endocardite/cirurgia , Endocardite Bacteriana/cirurgia , Humanos , Procedimentos Cirúrgicos VascularesRESUMO
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.