Implantation of a dual-chamber pacemaker with epicardial leads in adults using a minimally invasive subxyphoid approach.

BACKGROUND: Implantation of transvenous pacemaker systems is a standard method used to treat patients with bradycardia. There are some clinical settings in which that method cannot be used despite existing indications (such as developmental defects of the cardiovascular system and limited venous access or infections). In such cases, an epicardial pacing system may be implanted with cardiac surgery techniques, at a cost of certain surgical risks. The least invasive approach is subxyphoid, but it traditionally allows to place only a ventricular lead and achieve a single-chamber VVI pacing system. AIM: The aim of our study was to determine the feasibility of subxyphoid implantation of dual-chamber pacing systems using thoracoscopic tools, as well as to and examine the short- and mid-term outcomes of such procedures. METHODS: Patients were qualified for an epicardial pacemaker system in case of absolute indications for permanent pacing therapy and coexisting contraindications for a transvenous system. DDD systems were implanted in 10 consecutive patients, in general anesthesia, in a cardiac surgery operating room, using subxyphoid access to pericardial space and a standard set of minimally invasive thoracoscopic tools. RESULTS: Implantation of a dual-chamber pacing system using the above approach was successful in all attempts. No serious complications were observed. Pacing and sensing parameters were appropriate at implantation and remained such during the follow-up of 2-27 months. CONCLUSION: Implantation of a dual-chamber pacing system using a minimally invasive subxyphoid approach is feasible. Appropriate pacing and sensing values may be obtained and they remain stable during follow-up.

Sutureless Valves, a "Wireless" Option for Patients With Aortic Valve Disease: JACC State-of-the-Art Review.

Transcatheter technologies triggered the recent revision of the guidelines that progressively widened the indications for the treatment of aortic stenosis. On the surgical realm, a technology avoiding the need for sutures to anchor the prosthesis to the aortic annulus has been developed with the aim to reduce the duration of cardiopulmonary bypass and simplify the process of valve implantation. In addition to a transcatheter aortic valve replacement (TAVR)-like stent that exerts a radial force, these so-called "rapid deployment valves" or "sutureless valves" for aortic valve replacement also have cuffs to improve sealing and reduce the risk of paravalvular leak. Despite promising, the actual advantage of sutureless valves over traditional surgical procedures (surgical aortic valve replacement) or TAVR is still debated. This review summarizes the current comparative evidence reporting outcomes of "sutureless valves" for aortic valve replacement to TAVR and surgical aortic valve replacement in the treatment of aortic valve stenosis.

A Propensity Score Analysis of Early and Long-Term Outcomes of Retrograde Arterial Perfusion for Endoscopic and Minimally Invasive Heart Valve Surgery in Both Young and Elderly Patients.

(1) Background: Minimal invasive cardiac surgery via right anterolateral thoracotomy for heart valve surgery and other intracardiac procedures proven to have lower postoperative complications. We aim to compare the neurological complications and post-operative outcomes in two cohort groups as well as survival rates up to 5 years postoperatively; (2) Methodology: Retrospective observational study for patients who had minimally invasive cardiac valve surgery with retrograde femoral arterial perfusion between 2007 and 2021 (n = 596) and the categorized patients into two groups based on their age (≥70 years old and below 70). Propensity match analysis was conducted. The primary endpoint consisted of major postoperative complications and the secondary endpoint was the long-term survival rate. (3) Results: There was no difference between the two groups in terms of postoperative outcomes. Patients ≥ 70 years old had no increased risk for neurological complications (p = 0.75) compared with those below 70 years old. The mortality rate was also not significant between the two groups (p = 0.37) as well as the crude survival rates. (4) Conclusions: The use of retrograde femoral arterial perfusion in elderly patients is not associated with increased risk compared to the younger patients' group for a spectrum of primary cardiac valve procedures. Hence, minimally invasive approaches could be offered to elderly patients who might benefit from it.

Minimally invasive versus conventional sternotomy for Mitral valve repair: protocol for a multicentre randomised controlled trial (UK Mini Mitral).

INTRODUCTION: Numbers of patients undergoing mitral valve repair (MVr) surgery for severe mitral regurgitation have grown and will continue to rise. MVr is routinely performed via median sternotomy; however, there is a move towards less invasive surgical approaches.There is debate within the clinical and National Health Service (NHS) commissioning community about widespread adoption of minimally invasive MVr surgery in the absence of robust research evidence; implementation requires investment in staff and infrastructure.The UK Mini Mitral trial will provide definitive evidence comparing patient, NHS and clinical outcomes in adult patients undergoing MVr surgery. It will establish the best surgical approach for MVr, setting a standard against which emerging percutaneous techniques can be measured. Findings will inform optimisation of cost-effective practice. METHODS AND ANALYSIS: UK Mini Mitral is a multicentre, expertise based randomised controlled trial of minimally invasive thoracoscopically guided right minithoracotomy versus conventional sternotomy for MVr. The trial is taking place in NHS cardiothoracic centres in the UK with established minimally invasive mitral valve surgery programmes. In each centre, consenting and eligible patients are randomised to receive surgery performed by consultant surgeons who meet protocol-defined surgical expertise criteria. Patients are followed for 1 year, and consent to longer term follow-up.Primary outcome is physical functioning 12 weeks following surgery, measured by change in Short Form Health Survey (SF-36v2) physical functioning scale. Early and 1 year echo data will be reported by a core laboratory. Estimates of key clinical and health economic outcomes will be reported up to 5 years.The primary economic outcome is cost effectiveness, measured as incremental cost per quality-adjusted life year gained over 52 weeks following index surgery. ETHICS AND DISSEMINATION: A favourable opinion was given by Wales REC 6 (16/WA/0156). Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer reviewed publication. TRIAL REGISTRATION NUMBER: ISRCTN13930454.

An endoscopic repair of residual post-myocardial infarction ventricular septal defect.

Post-myocardial infarction (MI) ventricular septal defect (VSD) is a serious condition that is, fortunately, less diagnosed nowadays due to the advances in early diagnosis and treatment of ischaemic heart disease (incidence 1-2%). Despite the lower mortality of both surgical and interventional closure of the defect (25%) as compared to medical therapy (40-50%), there are still risks of residual leak in both approaches. Herein, we describe a case of a successful endoscopic-assisted repair of a delayed residual leak post-MI VSD after surgical repair. An attempt for interventional closure of the leaking point had failed; an endoscopic-assisted minimal access closure was successfully performed.

Endoscopic Tricuspid Valve Surgery is a Safe and Effective Option.

OBJECTIVE: Isolated tricuspid surgery through median sternotomy can be associated with a high morbidity and mortality. Reports of minimally invasive isolated tricuspid valve operations are rare, but the outcomes are encouraging. We present our experience of endoscopic isolated tricuspid valve surgery. METHODS: In our institution, 452 patients underwent endoscopic minimal access cardiac surgery between August 2008 and December 2018. A total of 90 patients underwent tricuspid valve surgery whether isolated or with other cardiac procedure. We further selected patients who had isolated tricuspid valve surgery (n = 24). Of these patients, 13 (54%) had more than one previous sternotomy. RESULTS: Tricuspid repair was performed in 18 patients (75%) with the remaining 6 (25%) having bioprosthetic tricuspid replacement. Three (12.5%) were performed with a beating heart, the remaining with endoaortic clamping and cardioplegia. There were no conversions to sternotomy. None of the patients had reoperation for bleeding, tamponade, or valve issues. Three patients (12.5%) required blood transfusion, 3 patients (12.5%) required renal dialysis, and 7 patients (29%) had respiratory complications such as chest infection, requiring continuous positive airway pressure (CPAP) with 2 being re-intubated. One patient (4.1%) died within 30 days from chest sepsis leading to multi-organ failure. Mean hospital stay was 11.1 ± 8.9 days (median of 8). All patients had mild or less regurgitation on follow-up echo at 6 months. CONCLUSIONS: Isolated tricuspid valve surgery can be performed through an endoscopic minimally access approach, with good results. It appears to provide better results than a sternotomy approach. A high repair rate can be achieved, and the procedure is particularly valuable in redo-surgery with low mortality and morbidity compared to historical sternotomy case series.

Transaortic transcatheter aortic valve implantation: Results of the Polish arm of the ROUTE registry.

BACKGROUND: Transaortic (TAo) transcatheter aortic valve implantation (TAVI) is an alter-native approach in patients considered to be at high risk for classical open surgery with poor peripheral vessel access. The purpose of this study was to determine the feasibility of using TAo access for TAVI procedures employing the Edwards SAPIEN transcatheter heart valve. The primary objective was to determine overall 30-day mortality. METHODS: A total of 32 patients with severe aortic valve stenosis underwent TAo-TAVI using Edwards SAPIEN bioprostheses. Postoperative results were collected according to the Registry of the Utilization Of the TAo-TAVI approach using the Edwards SAPIEN Valve (ROUTE) study protocol. Complications were assessed using Valve Academic Research Consortium- 2 (VARC-2) criteria. RESULTS: The mean age of the population was 80.9 ± 5.2 years, with 53.1% being female. All patients received either the SAPIEN XT or the SAPIEN 3 bioprosthesis (Edwards Lifesciences). Device success was achieved in 100% of cases. One (3.25%) patient subsequently suffered an aortic dissection and required ascending aorta replacement. Paravalvular leakage was absent or mild in 26 (81%) patients, and moderate in 6 (19%) patients. Other complications included permanent pacemaker implantation in 2 (6.5%), and transient post operative delirium in 2 (6.5%) patients. The total hospital stay was 6.7 ± 2.4 days. New York Heart Association class decreased significantly on follow-up. Thirty-day mortality rate was 2 (6.5%) patients. CONCLUSIONS: Use of TAo access for TAVI procedures has a reasonable clinical outcome and is a safe alternative to the transfemoral and transapical approaches, especially for patients with high-risk peripheral vessel access.