Longitudinal valvotomy of anterior leaflet for endoscopic transmitral myectomy for hypertrophic obstructive cardiomyopathy.

Transmitral myectomy for hypertrophic obstructive cardiomyopathy is compatible with minimally invasive surgery compared with traditional transaortic access. It has often been performed in conjunction with mitral valve replacement or temporary detachment of the anterior leaflet from its annulus. We present a novel approach: longitudinal incision at the midline of the anterior mitral leaflet for septal myectomy. The procedure is ideally conducted endoscopically or robotically through the right chest. Cardiopulmonary bypass is established in the usual manner. After cardioplegic arrest, the mitral valve is exposed, and the anterior mitral leaflet is incised longitudinally at the midline. Both parts of the leaflet are tentatively fixed to the atrial wall with sutures to keep them open. Using the look-up mode of a 30° scope, the right cusp of the aortic valve is observed. Myectomy is initiated close to the aortic annulus using the pure-cut mode of electrocautery and scissors, then extended apically as necessary. After myectomy, the anterior leaflet is reapproximated with interrupted sutures. This technique is simpler than the detachment of the anterior leaflet and does not require patch materials that could lead to durability issues for the reconstruction of the anterior leaflet.

Staged endoscopic mitral valve repair for active infective endocarditis with a mitral annular abscess.

The presence of an annular abscess complicates the operation for infective endocarditis. We report a case of a totally endoscopic repair of a mitral annular abscess using a staged strategy. A 28-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis with Staphylococcus aureus. At the index operation, the mitral annular abscess was completely debrided, yielding an annular defect. The mitral valve was repaired with the autologous pericardial patch and an annuloplasty. Primary repair of the annular defect was not performed because of the fragility of oedematous tissues. Two weeks after index surgery, when the infection was under control, and the scar tissue had formed around the annulus, we performed the second stage operation involving repair of the annular abscess. The scar formation enabled annular reconstruction and additional repair of the mitral valve in a totally endoscopic fashion. The postoperative course was uneventful, and there was no recurrence at 5 months. An annular abscess may be repaired with staged surgery in select situations.

Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery.

BACKGROUND: The applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types. METHODS: A total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures. RESULTS: Of 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures. CONCLUSIONS: Endoscopic AVR can safely address concomitant valve diseases.

Left ventricular pseudoaneurysm after endoscopic mitral valve repair for active endocarditis.

A left ventricular pseudoaneurysm is a rare complication that can occur after infective endocarditis, possibly leading to serious complications such as cardiac tamponade, rupture and recurrent infective endocarditis. We report a case of a totally-endoscopic repair of a pseudoaneurysm after endoscopic mitral valve repair. A 48-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis. A left ventricular pseudoaneurysm was found 2 weeks after the surgery. The pseudoaneurysm was repaired through a left thoracotomy with a totally endoscopic platform. The postoperative course was uneventful, and there was no recurrence at 18 months. Left ventricular pseudoaneurysm may be repaired with a left thoracotomy totally endoscopic approach.

Midterm results after seamless patch mitral reconstruction.

Objectives: Some pathologies, including infective endocarditis or sclerotic changes of the mitral leaflet, make the conventional mitral valve repair challenging. Our previously described technique for reconstruction with a seamless pericardial patch makes the repair feasible in some of such difficult pathologies. However, the extent of mitral leaflet segments that could be safely repaired using this technique remains unknown. We investigated the association between the midterm outcome and the extent of mitral leaflet segments replaced by a pericardial patch. Methods: From January 2009 to January 2022, patients who underwent mitral valve repair with the seamless 1-patch reconstruction technique were included. The glutaraldehyde-treated pericardium was trimmed and anchored at the papillary muscle. The edge was sewn to the leaflet and the annulus. Results: A total of 49 patients (aged 60 ± 15 years) underwent mitral valve repair with this technique. The totally endoscopic approach was used in 27 patients (55%). No patient's repair was converted to valve replacement. No operative mortality or disabling stroke was observed during the early postoperative period. In the midterm follow-up, redo surgery was required in 9 patients (18%). Freedom from mitral valve reintervention rates at 1, 5, and 10 years were 84%, 82%, and 82% for all patients, respectively. Freedom from reoperation at 5 years was 100%, 92%, and 46% for commissural lesion, 1- to 2-segment involvement, and 3-segment involvement, respectively. There was a significant difference among the 3 groups with regard to mitral valve reoperation rate (P = .002). Conclusions: Mitral valve seamless patch reconstruction provides excellent midterm results if applied to commissural lesions or lesions involving up to 2 segments.

Endoscopic mitral valve repair utilizing cavitron ultrasonic surgical aspirator for active endocarditis.

Mitral valve repair for endocarditis in an acute setting is still challenging due to difficulties in debriding friable tissue and in leaving enough non-infected tissue for reconstruction. Endoscopic approaches for complex mitral valve procedures via a minimally invasive approach have been reported from high-volume programs. However, the role of endoscopic mitral valve surgery for acute infective endocarditis has not been clearly defined. We report our technique of endoscopic mitral valve repair using the cavitron ultrasonic surgical aspirator system for active endocarditis. The cavitron ultrasonic surgical aspirator with a low power setting provides enough debridement of the infective tissue and leaves healthy tissue adequate for repair under a totally endoscopic vision.

Use of a cutting stapler to excise a left atrial appendage in minimally invasive cardiac surgery.

PURPOSE: A cutting stapler is a well-established instrument in many surgical fields. However, its efficacy and safety have not been proven yet in resecting a left atrial appendage (LAA) in minimally invasive cardiac surgery (MICS). METHODS: A cutting stapler was used to resect the LAA in 98 consecutive patients who underwent MICS. Of these, 26 patients underwent aortic valve replacement, 72 mitral valve repair/replacement, 25 tricuspid annuloplasty, 7 closure of atrial septal defect, and 26 the Maze procedure (contains overlapping). The ascending aorta was elevated using a retractor, and a 12-mm shaft motor-driven cutting stapler was inserted through the transverse sinus. As a control group, 150 patients who underwent suture resection/closure of the LAA either from inside or outside were compared. RESULTS: There was one mortality in each group. They were not related to the LAA resection/closure. In the suture group, the LAA suture was taken down in one patient because of a suspected obstruction of the circumflex artery, and two patients had re-exploration for bleeding from the LAA. In the stapler group, there was no complication related with the LAA. The rate of complication did not reach a statistical difference. CONCLUSION: A cutting stapler is considered to be a useful instrument to resect the LAA in MICS.

[Totally Endoscopic Aortic Valve Replacement Using the Three-dimensional Endoscope].

Totally endoscopic aortic valve replacement (TE-AVR) is still challenging, and few series report exist even today. In 2015, we started to use three-dimensional (3D) endoscope and we also introduced TE-AVR. Patient is placed in the partial left lateral position. The main wound is created in right antero-lateral 4th intercostal space through 4 cm skin incision. No rib spreader is used. 3D endoscope is inserted on the mid-axillary line. A 5 mm trocar was inserted in the 3rd intercostal space, thus creating 3-port setting similarly to that for endoscopic mitral valve surgery. All sutures are tied using a knot-pusher. We have performed 106 cases of TE-AVR. Compared with transaxillary AVR, there were no significant differences between the 2 groups in the hospital deaths or MACCE. Postoperative hospital stays became shorter in totally endoscopic group. In conclusion, TE-AVR was possible through 3 ports created in the right antero-lateral chest similarly to the endoscopic mitral valve surgery. Transaxillary approach seemed to be suitable for the TE-AVR. By adopting common approach for both mitral valve surgery and aortic valve surgery, endoscopic double valve surgery could be performed seamlessly.

Interaction of Lipoplex with Albumin Enhances Gene Expression in Hepatitis Mice.

Understanding the in vivo fate of lipoplex, which is composed of cationic liposomes and DNA, is an important issue toward gene therapy. In disease conditions, the fate of lipoplex might change compared with the normal condition. Here, we examined the contribution of interaction with serum components to in vivo transfection using lipoplex in hepatitis mice. Prior to administration, lipoplex was incubated with serum or albumin. In the liver, the interaction with albumin enhanced gene expression in hepatitis mice, while in the lung, the interaction with serum or albumin enhanced it. In normal mice, the interaction with albumin did not enhance hepatic and pulmonary gene expression. Furthermore, hepatic and pulmonary gene expression levels of albumin-interacted lipoplex were correlated with serum transaminases in hepatitis mice. The albumin interaction increased the hepatic accumulation of lipoplex and serum tumor necrosis factor-α level. We suggest that the interaction with albumin enhanced the inflammation level after the administration of lipoplex in hepatitis mice. Consequently, the enhancement of the inflammation level might enhance the gene expression level. Information obtained in the current study will be valuable toward future clinical application of the lipoplex.

Left-Sided Complete Revascularization With Bilateral Internal Thoracic Arteries in Patients With Diabetes.

BACKGROUND: Reports are few on the long-term patency of bilateral internal thoracic artery (BITA) grafts in patients with diabetes. We evaluated the relationship between the long-term patency of BITAs and the clinical outcomes in diabetes. METHODS: We retrospectively identified 569 patients (321 with diabetes, 248 without diabetes) who underwent isolated BITA grafting for left-sided complete revascularization at our institution from 2000 to 2015. The primary end point was the incidence of major adverse cardiovascular events comprising death, re-revascularization, and myocardial infarction. The secondary end point was the patency of the BITAs. RESULTS: No differences were found in the major adverse cardiovascular event rate (10-year: diabetic group, 33.7%; nondiabetic group, 22.3%; p = 0.15) or overall mortality rate (24.0% versus 12.2%, p = 0.066) between the patients with and without diabetes. The incidence of cardiac death (3.3% versus 1.8%, p = 0.80) or re-revascularization and myocardial infarction (11.4% versus 11.8%, p = 0.67) was similar between the groups. The patency of free internal thoracic artery (ITA) grafts to the left circumflex artery was associated with greater patency in patients with diabetes than in patients without diabetes (4 years: 99.3% versus 95.5%, p = 0.049); the patency of other ITA grafts did not differ between the groups. CONCLUSIONS: All-cause death, re-revascularization, and myocardial infarction showed no differences between patients with and without diabetes who underwent left-sided revascularization with the BITAs. Although diabetes did not affect the patency of the ITA, free ITA grafts to the left circumflex artery showed good long-term patency in patients with diabetes.