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.

Mid-term outcomes of non-resectional chordal foldoplasty for degenerative mitral regurgitation.

OBJECTIVES: We aimed to evaluate the mid-term clinical and echocardiographic outcomes of chordal foldoplasty performed for non-resectional mitral valve repair in degenerative mitral valve disease with a large posterior leaflet. METHODS: We reviewed 82 patients undergoing non-resectional mitral valve repair via chordal foldoplasty between October 2013 and June 2021. We analysed operative outcomes, mid-term survival rate, freedom from reoperation and freedom from recurrent moderate or severe mitral regurgitation (MR). RESULTS: The mean age of patients was 57.2 ± 12.4 years; 61 patients (74%) had posterior leaflet prolapse, 21 patients (26%) had bileaflet prolapse and all of them had at least 1 tall posterior leaflet scallop. Minimally invasive approach with a right mini-thoracotomy was used in 73 patients (89%). The operative mortality was zero. There was no conversion to mitral valve replacement and postoperative echocardiography revealed no more than mild residual regurgitation or systolic anterior motion. Five-year survival rate, freedom from mitral reoperation and freedom from recurrent moderate/severe MR were 93.9%, 97.4% and 94.5%, respectively. CONCLUSIONS: Non-resectional chordal foldoplasty is a simple and effective repair technique for select degenerative MR cases with a tall posterior leaflet.

Endoscopically assisted selective antegrade cardioplegia in minimally invasive aortic valve replacement for patients with aortic insufficiency.

Objective: In minimally invasive aortic valve replacement via a right minithoracotomy for patients with significant aortic insufficiency, optimal cardioplegia delivery procedures remain controversial. This study aimed to describe and evaluate endoscopically assisted selective cardioplegia delivery in minimally invasive aortic valve replacement for aortic insufficiency. Methods: Between September 2015 and February 2022, 104 patients (mean age, 66.0 ± 14.3 years) with moderate or greater aortic insufficiency underwent endoscopically assisted minimally invasive aortic valve replacement at our institutions. For myocardial protection, potassium chloride and landiolol were systemically administered before aortic crossclamping, and cold crystalloid cardioplegia was delivered selectively to the coronary arteries using step-by-step endoscopic procedures. The early clinical outcomes were also evaluated. Results: Eighty-four patients (80.7%) had severe aortic insufficiency, and 13 patients (12.5%) had aortic stenosis and moderate or greater aortic insufficiency. A regular prosthesis was used in 97 cases (93.3%), and a sutureless prosthesis was used in 7 cases (6.7%). The mean operative, cardiopulmonary bypass, and aortic crossclamping times were 169.3 ± 36.5, 102.4 ± 25.4, and 72.5 ± 21.8 minutes, respectively. No patients underwent a conversion to full sternotomy or required mechanical circulatory support during or after surgery. No operative deaths or perioperative myocardial infarctions occurred. The median intensive care unit and hospital stays were 1 and 5 days, respectively. Conclusions: Endoscopically assisted selective antegrade cardioplegia delivery is safe and feasible for treating minimally invasive aortic valve replacement in patients with significant aortic insufficiency.

Impact of the Cardioplegia Interval on Myocardial Protection Using the Modified St. Thomas Solution in Minimally Invasive Mitral Valve Surgery: A Double-Center Study.

It has been reported that a single-dose cardioplegia interval is useful, but the safe interval doses are not clear. We aimed to investigate the impact of the cardioplegia interval on myocardial protection using the modified St. Thomas solution. We included consecutive isolated minimally invasive mitral valvuloplasty procedures (n = 229) performed at a hospital and medical center from January 2014 to December 2020. We compared postoperative peak creatine kinase MB and creatine kinase levels and other indicators between the short (Group S, n = 135; maximum myocardial protection interval <60 minutes) and long (Group L, n = 94; maximum myocardial protection interval ≥60 minutes) interval groups. Propensity score matching was used to adjust for confounders between the two groups. After propensity score matching, Groups S and L contained 47 patients each. Groups S and L did not differ significantly in peak creatine kinase MB (45.8 ± 26.3 IU/L and 41.5 ± 27.9 IU/L, respectively; p = .441) and creatine kinase levels (1,133 ± 567 IU/L and 1,100 ± 916 IU/L, respectively; p = .837) after admission to the intensive care unit on the day of surgery based on propensity score matching. In multivariate analysis, a cardioplegia dosing interval ≥60 minutes was not significantly associated with the maximum creatine kinase MB level after admission to the intensive care unit on the day of surgery (p = .354; 95% confidence interval: -1.67 to 4.65). Using the antegrade modified St. Thomas solution, the long interval dose method is useful and safe in minimally invasive mitral valvuloplasty.

Double-leaflet Technique for Mitral Regurgitation With Small or Tethered Posterior Leaflet.

Small leaflets make mitral valve repair procedures challenging. Our double-leaflet technique creates a new autologous pericardial leaflet attached to the papillary muscle, annuloplasty ring, and neighboring scallops above the small or tethered posterior leaflet. This simple additional technique provides deep coaptation after mitral valve repair for both degenerative and functional mitral regurgitation with the small or tethered posterior leaflet.

Refractory heart failure and intermittent claudication secondary to supra-renal coral reef aorta.

Coral reef aorta (CRA), a rare disease, is characterized by severe calcification of the juxta-renal and suprarenal aorta that grows into the lumen and leads to severe stenosis. A 70-year-old woman with refractory hypertension and lower limb claudication presented with hypertension and congestive heart failure. Treatment with vasodilators and diuresis led to oliguria and exacerbated kidney function, while her congestion remained. Abdominal computerized tomography showed a bulky, irregular localized supra-renal aortic calcification with stenosis. A peripheral artery ultrasound and angiography showed no occlusive lesions in the distal run-off vessels. Based on her medical history and the unique aspects of the localized calcified lesion, CRA was diagnosed. We suspected that the congestive heart failure, refractory hypertension, and renal failure resulted from the supra-renal aortic stenosis. Because she developed oliguria with diuretics and vasodilators, we performed an open graft replacement with a thoracoabdominal approach. The reddish-brown calcified mass came off easily and was very fragile. The postoperative course was uneventful, and her heart and renal failure were completely resolved. This is the first report showing the fragility of CRA. Considering its fragility, catheter treatment may need to be avoided to prevent distal embolism. .

Modified commissural plication in mitral valve repair for commissural prolapse.

Commissural plication is a simple and useful technique for commissural prolapse repair. However, simple plication may not work when the diseased commissure is thick or calcified. In such cases, we incise the commissure towards the annulus and bring two separate parts of the commissural leaflet back together by sewing the atrial sides of each part. This modified commissural plication technique is still very simple and effective even for thick or calcified commissural lesions because it minimizes tension on the commissural sutures.

Papillary fibroelastoma entangled with tendinous chords: gap between echocardiographic and operative findings.

This papillary fibroelastoma case showed the imaging gap between echocardiography and operative findings. Use of 4K endoscopy enabled us to visualize the details of the tumor and to excise it safely.