Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience.

BACKGROUND: Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery. METHODS: Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV. RESULTS: Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high. CONCLUSIONS: The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.

Ischemic gastric ulcer after coronary bypass using the right gastroepiploic artery.

The gastroepiploic artery has been widely used for complete arterial myocardial revascularization of young patients. Gastric complications related to the harvesting of this artery are exceptional. We describe here a case of ischemic gastric ulcer due to the use of a gastroepiploic artery in a patient with severe celiac trunk disease. The patient was cured by angioplasty completed by a stenting procedure.

Video-assisted Port-Access combined mitral valve and CABG surgery.

Although conventional right thoracotomy is a well-known alternative for mid-sternotomy to access the left atrium, a combined video-assisted mitral and left anterior descending (LAD) approach via Port-Access has not yet been described. We report the case of a 68-year-old patient with severe mitral valve regurgitation due to myxoid degeneration associated with a critical LAD coronary artery stenosis. A totally video-assisted 'true' Port-Access (i.e. no costal retraction) mitral valve repair and direct coronary artery bypass were performed in combination, without complications.

Minimally invasive video-assisted mitral valve repair: short and mid-term results.

BACKGROUND AND AIM OF THE STUDY: Port-Access video-assisted surgery for mitral valve repair has become an alternative for mid-sternotomy. However, mid-term results are not yet available. METHODS: Between February 1997 and December 1999, 121 patients underwent mitral valve surgery through a 4- to 5-cm right anterolateral thoracotomy using the Heartport endovascular cardiopulmonary bypass system; among these patients, 77 (57 males, 20 females; mean age 59 years; range 31-84 years) underwent mitral valve repair. Severe (4+) mitral regurgitation (MR) was seen in 63 patients (82%). Mean NYHA class was 2.5+/-0.4. Standard Carpentier mitral valve repair procedures were used in all patients; 11 received PTFE chordae for anterior leaflet prolapse. RESULTS: Pathologies were degenerative (n = 69), chronic endocarditis (n = 4), annular dilatation (n = 3) and rheumatic (n = 1). Hospital mortality was 1.3% (n = 1). Two patients (2.6%) had conversion to sternotomy for aortic dissection caused by the Endo-Aortic Clamp. Nine patients (11%) underwent revision for bleeding. Mean cross-clamp and perfusion times were 103 min (range: 24-160 min) and 140 min (range: 75-215 min), respectively. Mean hospital stay was eight days (range: 4-36 days). During follow up (mean 31 months; range: 17-51 months) all patients improved their NYHA class; eight (11%) remained in class II. Left ventricular (LV) end-diastolic and LV end-systolic diameters decreased from 61+/-7.3 mm to 53+/-6.9 mm (p <0.01) and from 37+/-6.8 mm to 34+/-6.9 mm (p <0.05), respectively. Sixty-two patients (88%) had no or trivial MR, and nine (12%) had moderate MR (2+). There were two late valve replacements for endocarditis, and no late deaths. CONCLUSION: Port-Access mitral valve repair constitutes a valid alternative to the standard procedure, and has good mid-term results. Video-assisted mitral valve repair appears to be safe and reproducible.

Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery.

OBJECTIVE: The surgical treatment of poststernotomy acute mediastinitis remains challenging. After disappointing results with a conservative management of post coronary artery bypass grafting (CABG) mediastinitis, we shifted towards a more aggressive surgical management. METHODS: From March 1993 until December 1999, 32 patients (6 female/26 male), 0.5% of the total sternotomy population, were operated for mediastinitis, defined as wound and sternal dehiscence with medistinal pus and positive culture. Mean age was 66 years (32-79 years). Twenty-two patients (75%) underwent CABG and 16 patients were in New York Heart Association (NYHA) class III/IV. RESULTS: We performed an omentoplasty in 11 patients, a pectoralis muscle flap associated with an omentoplasty in 20 patients. One patient had a bilateral pectoralis myoplasty. The reconstruction surgery occurred at an average of 11 days (6-26) after primary surgery. Twelve patients had a previous surgical drainage (1-3 surgical procedures) of the mediastinum. Hospital mortality was nine patients (28%). Seven of these patients (77%) were in NYHA IV with inotropic support. Five patients had to be reoperated on: four patients had a bilateral myoplasty after omentoplasty, one patient had an omentoplasty after a unilateral myoplasty. Late epigastric hernia was seen in three patients, two patients had wound revision and one had a retroperitoneal drainage for pancreatitis. There were no early or late flap failures. CONCLUSION: In our experience, omental and pectoralis flaps for poststernotomy acute mediastinitis provides good outcome of our stable patients. We would be reluctant to use it as standard therapy in our unstable patients.

Management of hepatic artery aneurysm. Case report and literature review.

The authors report the case of a 72-year-old man with new but vague epigastric pain. CT scan and selective coeliac trunk angiography demonstrated a common hepatic artery aneurysm (HAA). He was treated surgically by ligation and excision without revascularization. Asymptomatic hepatic aneurysm should be treated aggressively because the natural course seems to be progression to rupture associated with a high mortality rate. The authors discuss the clinical scenario of patients with HAA and stress the importance of the early treatment. In addition the therapeutic options are explored.

Video-assisted Port-Access surgery for radical myxoma resection.

The curative treatment of choice for myxomas is surgical removal. Most of the patients are young and active and are focused on postoperative comfort, cosmesis and a fast track to complete rehabilitation, all of which is related to the degree of invasiveness of the intervention. We report our first experience with video-assisted Port-Access surgery for atrial myxoma. From February 1997 until April 2000, nine patients (3M/6F)) had an atrial myxoma resection with the Heartport Endo-CPB and Endo-aortic clamp system. Mean age was 54 +/- 21.9 years. Most of the patients were symptomatic and had good LV function. Two patients had a combined procedure: one mitral valve replacement and one vascular shunt for dialysis. Mean aortic cross clamp time was 69 +/- 32.8 min and mean perfusion time was 103 +/- 42.7 min. There were no conversions to sternotomy. Three patients had minor complications. Mean ICU and hospital stay were 1 +/- 1.4 and 6 +/- 3.9 days respectively. No thromboembolic or peripheral ischaemic complications were observed. There were no hospital deaths. No recurrent tumors have been identified. The Port-Access approach for myxoma resection constitutes a invaluable alternative to sternotomy with the same gold standards of results and quality.

[Complications of laparoscopic cholecystectomy. Free intraperitoneal calculi]. / Complications de la cholécystectomie par coelioscopie. Devenir des calculs intra-péritonéaux libres.

With the use of laparoscopic cholecystectomy, increasing numbers of gallstones are being left in the peritoneal cavity. To our knowledge, the rarely cause complications. We present two cases with stone spillage after laparoscopic cholecystectomy, with a different outcome.

Endovascular treatment of the descending thoracic aorta.

OBJECTIVES: to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology. DESIGN: retrospective single center study. MATERIAL AND METHODS: between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12). RESULTS: successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft. CONCLUSIONS: endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.

Effect of PGI2 and thromboxane antagonist on liver ischemic injury.

Thromboxane, prostacyclin and their ratio could play an important role in the ischemic liver injury. To study this hypothesis, thromboxane and prostacyclin were measured by RIA after incubation of liver tissues removed during and after an ischemia of 90 min in male Wistar rats. The thromboxane to prostacyclin ratio increases during this period. In order to examine if this change could influence the survival rate of animals submitted to the same period of ischemia, drugs able to reduce the relative predominance of thromboxane were infused. The survival rate was not modified by administration of Iloprost or Daltroban, the antagonist of the thromboxane receptors. By contrast, imidazole, an inhibitor of thromboxane synthetase, significantly increased the survival rate. The same result was obtained with the administration of Daltroban plus Iloprost, suggesting that the reduction of thromboxane action associated with the increase of PGI2 level reduces the ischemic injury.

Angiosarcoma of the thyroid and concurrent hyperthyroidism.

We describe the exceptional association of an angiosarcoma of the thyroid and hyperthyroidism in a 74-year-old woman who presented with a toxic multinodular goiter of recent growth. This association reported in two other cases may not be fortuitous but due a vascular effect of the angiosarcoma contributing to the development of thyrotoxicosis. This case also illustrates the diagnostic difficulties and the poor prognosis of this tumor.