Three-Dimensional Endoscopic-Assisted Concomitant Mitral and Aortic Valve Surgery.

Minimally invasive cardiac surgery is commonly used to treat degenerative mitral regurgitation. The totally endoscopic approach has emerged as an attractive alternative procedure especially for young patients and has been described in isolated mitral and aortic valve settings. The totally endoscopic double valve procedure, including mitral and aortic valves, extends this treatment option to a broader patient population. We describe our approach to performing a totally endoscopic concomitant aortic and mitral valve procedure that has overcome unique technical hurdles and has yielded favorable outcomes.

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.

Totally endoscopic aortic valve replacement via an anterolateral approach using a standard prosthesis.

OBJECTIVES: Totally endoscopic aortic valve replacement (AVR) is still a challenging operation, and only a few series reports exist in the literature. The purposes of this study were to establish a method for endoscopic AVR and evaluate its initial results. METHODS: A total of 47 patients (median age 76 years, 17 men) underwent endoscopic AVR. The main wound was created in the right anterolateral 4th intercostal space through a 4-cm skin incision. No rib spreader was used. A 3-dimensional endoscope was inserted at the midaxillary line. A 5.5-mm trocar was inserted in the 3rd intercostal space, thus creating a 3-port setting similar to that used for endoscopic mitral valve surgery. A standard prosthesis was used, and the sutures were tied using a knot pusher. Results were compared with those of 157 patients who underwent right transaxillary AVR with direct vision plus endoscopic assist. RESULTS: Patient backgrounds did not differ significantly between the 2 groups. No deaths occurred in the entire series. There was no conversion to thoracotomy or sternotomy in the endoscopic AVR group. The complication rate did not differ significantly between the 2 groups. The total operating time was significantly shorter in endoscopic AVR (188-206 min); the cardiopulmonary bypass time (130-128 min) and the cross-clamp time (90-95 min) did not differ significantly (median, endoscopic AVR, right transaxillary AVR). Two patients underwent endoscopic double-valve (aortic and mitral) surgery under the same conditions. CONCLUSIONS: Endoscopic AVR was possible through 3 ports created in the right anterolateral chest, similar to the procedure for endoscopic mitral valve surgery. By adopting a common approach for both the aortic and the mitral valve operations, endoscopic double-valve surgery can be performed seamlessly.

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.

Three-port totally endoscopic repair vs conventional median sternotomy for atrial septal defect.

PURPOSES: We assessed the validity of three-port totally endoscopic repair (3PTER) for atrial septal defect (ASD). METHODS: Between February, 2000 and November, 2017, 151 patients underwent surgery for ASD. Forty-seven patients underwent 3PTER as minimally invasive cardiac surgery (MICS) and 104 patients underwent conventional median sternotomy (CMS). Propensity matching yielded 94 matched patients (47 vs 47). We compared the early results between the groups. The 3PTER technique was performed with the patient in the partial left lateral position, under cardio-pulmonary bypass (CPB) established through a groin incision. The three ports consisted of a main incision (3 cm), a trocar for the left-handed instrument, and a camera port in right antero-lateral chest. RESULTS: MICS needed longer cross clamp and CPB times (57, 48-86 vs 24, 16-30 min, p < 0.01 and 115, 106-131 vs 53, 43-80 min, p < 0.01, respectively)*, although the operation time and hospital stay were significantly shorter (180, 159-203 vs 190, 161-225 min, p = 0.024 and 6.0, 6-8 vs 15, 13-19 days, p < 0.01, respectively)*. The intra-operative and postoperative bleeding were significantly less in MICS than CMS (20, 5-40 vs 225, 130-287.5 p < 0.01 and 200, 145-290 vs 340, 250-535 ml, p < 0.01, respectively)*. *: median, 25th-75th percentile. CONCLUSION: Irrespective of the longer CPB and cross-clamp time than for CMS, MICS had a shorter operation time, less bleeding, and resulted in quicker recovery. The 3PTER was safe and cosmetically excellent.

Trans-right axillary aortic valve replacement: propensity-matched comparison with standard sternotomy approach.

OBJECTIVES: We developed trans-right axillary aortic valve replacement (TAX-AVR) as a more cosmetically superior approach to minimally invasive AVR. We herein retrospectively compared the safety and invasiveness between TAX-AVR and conventional AVR (C-AVR). METHODS: TAX-AVR was performed under femorofemoral cardiopulmonary bypass. Creation of a small right axillary vertical skin incision was followed by anterolateral intercostal thoracotomy. AVR was performed using long-shafted minimally invasive instruments, a knot pusher and endoscopic assistance. From January 2007 to June 2016, 112 patients underwent TAX-AVR and 183 controls underwent first-time, isolated non-emergency C-AVR. The factors used to calculate the European System for Cardiac Operative Risk Evaluation score and Society of Thoracic Surgeons score were adopted for propensity matching. Early mortality and major adverse cardiac and cerebral events were compared. The procedural time, postoperative intensive care unit stay and hospital stay were compared as markers of invasiveness. RESULTS: Propensity matching generated 108 matched pairs with similar backgrounds. Thirty-day mortality occurred in 0 and 1 patient in the TAX-AVR and C-AVR groups, respectively. The major adverse cardiac and cerebral events rates were not significantly different between the groups. The average aortic clamp time was longer (100 vs 94 min), but the intensive care unit stay (1.2 vs 1.8 days) and hospital stay (10.0 vs 12.5 days) were shorter in the TAX-AVR group. Postoperative blood loss, transfusion and atrial fibrillation were lower in the TAX-AVR group. The average prosthesis size was 22 mm in both groups. CONCLUSIONS: TAX-AVR is as safe as C-AVR and less invasive in terms of a shorter recovery period.