Thoracic endovascular repair of descending thoracic aorta aneurysm using thoracic stent graft in a challenging complex patient: An innovative access technique during an emergency using a mini-thoracotomy approach.

OBJECTIVES: Repairing thoracic aortic aneurysms with endovascular aortic repair (TEVAR) is a safe and minimally invasive method with low morbidity and short postoperative recovery. We developed a novel method to treat descending thoracic aortic aneurysms using a mini-thoracotomy approach in complex patients with difficult access. METHODS: A 56-year-old male patient presented with a 3-day history of chest pain. His past surgical history included infrarenal aortic ligation and right axillobifemoral bypass. Thoracic computed tomography angiography (CTA) revealed a saccular aortic aneurysmal dilatation at zone 2 measuring 4.4 × 4 cm. Owing to his surgical history, vascular access through the femoral and iliac arteries or abdominal aorta was impossible. We developed a new technique using a left posterolateral mini-thoracotomy approach to gain vascular access and perform TEVAR, avoiding the need for an open thoracotomy repair. RESULTS AND CONCLUSIONS: Thoracic CTA performed before discharge revealed complete aneurysmal exclusion and no endoleaks. Postoperative follow-up CTA (6 months and annually thereafter) revealed no aneurysm formation or aortic restenosis. The femoral artery, followed by the iliac artery, is the traditional access route for TEVAR. Left posterolateral mini-thoracotomy may be required as an alternative access in complex patients.

[Mitral valve surgery via minimally invasive and conventional access]. / Mitral'naya khirurgiya iz mini- i traditsionnogo dostupov.

OBJECTIVE: To compare the immediate results of mini-thoracotomy and sternotomy in patients with mitral valve disease. MATERIAL AND METHODS: The study included 52 patients who underwent mitral valve surgery (25 cases - mini-thoracotomy, 27 cases - sternotomy). RESULTS: Aortic cross-clamping time was significantly longer in sternotomy compared to mini-thoracotomy group - 110 vs 94 min (p=0.03). Ventilation time was also significantly longer in the sternotomy group (12 vs. 8 hours, p=0.01). Postoperative morbidity was similar (postoperative wound infection, neurological complications, coronavirus disease, overall in-hospital mortality). CONCLUSION: In addition to cosmetic effect, minimally invasive approach in mitral valve surgery has some other advantages including less duration of aortic cross-clamping and mechanical ventilation, availability of reconstructive interventions due to better exposition of the mitral valve and subvalvular structures.

Comparative effects of minimally invasive approaches vs. conventional for obese patients undergoing aortic valve replacement: a systematic review and network meta-analysis.

BACKGROUND: Minimally invasive approaches like mini-thoracotomy and mini-sternotomy for Aortic Valve Replacement (AVR) showed impressive outcomes. However, their advantages for obese patients are questionable. We aimed in this network meta-analysis to compare three surgical approaches: Full sternotomy (FS), Mini-sternotomy (MS), and Mini-thoracotomy (MT) for obese patients undergoing AVR. METHODS: We followed the PRISMA extension for this network meta-analysis. PubMed/Medline, Scopus, Web of Science, and Cochrane searched through March 2023 for relevant articles. The analysis was performed using R version 4.2.3. RESULTS: Out of 344, 8 articles met the criteria with 1392 patients. The main outcomes assessed were perioperative mortality, re-exploration, atrial fibrillation, renal failure, ICU stay, hospital stay, cross-clamp time, and bypass time. In favor of MS, the length of ICU stay and hospital stay was significantly lower than for FS [MD -0.84, 95%CI (-1.26; -0.43)], and [MD -2.56, 95%CI (-3.90; -1.22)], respectively. Regarding peri-operative mortality, FS showed a significantly higher risk compared to MS [RR 2.28, 95%CI (1.01;5.16)]. Also, patients who underwent minimally invasive approaches; MT and MS, required less need of re-exploration compared to FS [RR 0.10, 95%CI (0.02;0.45)], and [RR 0.33, 95%CI (0.14;0.79)], respectively. However, Intraoperative timings; including aortic cross-clamp, and cardiopulmonary bypass time, were significantly lower with FS than for MS [MD -9.16, 95%CI (-1.88; -16.45)], [MD -9.61, 95%CI (-18.64; -0.59)], respectively. CONCLUSION: Our network meta-analysis shows that minimally invasive approaches offer some advantages for obese patients undergoing AVR over full sternotomy. Suggesting that these approaches might be considered more beneficial alternatives for obese patients undergoing AVR.

Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis.

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis.

Minimally Invasive Valvular Surgery in the Elderly　- Safety, Early Recovery, and Long-Term Outcomes.

BACKGROUND: For elderly people, the benefit of minimally invasive cardiac surgery (MICS) is unclear, so we evaluated the safety, recovery, and long-term survival in elderly MICS patients.Methods and Results: 63 propensity score-matched pairs of 213 consecutive patients (≥70 years old) who underwent mitral and/or tricuspid valve surgery between 2010 and 2020 (121 right mini-thoracotomies vs. 92 full sternotomies) were compared. The primary outcome was safety (composite endpoint of in-hospital death or major complication). Secondary outcomes were early ambulation and discharge to home. There were no differences between the groups for in-hospital death (3.2% vs. 0.0%, P=0.157) and primary outcome (14.3% vs. 17.5%, P=0.617). The rate of early ambulation (73.0% vs. 55.6%, P=0.048) and discharge to home (66.7% vs. 49.2%, P=0.034) were significantly higher in the mini-thoracotomy group. Major complication was an independent negative predictor of early ambulation for mini-thoracotomy but not for a conservative approach. Survival was 87.8±4.4% vs. 86.8±4.7% at 5 years, which was not significantly different. CONCLUSIONS: Similar safety but better recovery were observed for mini-thoracotomy, and long-term survival was comparable between groups. Major complication was a negative predictor of early ambulation after mini-thoracotomy. Careful preoperative risk stratification would enhance the benefits of MICS in elderly patients.

Transaortic Transcatheter Aortic Valve Replacement in Patients From a Single Institution　- Feasibility, Safety, and Midterm Outcomes.

BACKGROUND: Transaortic transcatheter aortic valve replacement (TAo-TAVR) is an alternative to peripheral or transapical TAVR. The procedural feasibility, safety, and midterm outcomes of TAo-TAVR were investigated in this study.Methods and Results:Eighty-four consecutive patients underwent TAo-TAVR from 2011 to 2021. Their median age was 83 years (interquartile range, 80-87 years). The Edwards SAPIEN and Medtronic CoreValve devices were used in 45 (53.6%) and 38 (45.2%) patients, respectively. The surgical approach was a right mini-thoracotomy in 43 patients (51.2%) and partial sternotomy in 4 patients (4.8%). The remaining 37 patients (44.0%) underwent full sternotomy because of concomitant off-pump coronary artery bypass grafting. VARC-3 device success was achieved in 77 patients (91.7%). Valve migration occurred in 3 patients (3.6%) using a first-generation CoreValve device, necessitating implantation of a second valve. No aortic annulus rupture, aortic dissection, or coronary orifice occlusion occurred. Conversion to surgery was required for 1 patient because of uncontrollable bleeding. Only 1 in-hospital death occurred. New pacemaker implantation was required in 6 patients (7.1%). Echocardiography at discharge showed no or trivial paravalvular leak (PVL) in 58 patients (69.0%), mild PVL in 23 (27.4%), and mild to moderate PVL in 2 (2.4%) patients. The 1- and 3-year incidence of cardiovascular death was 1.6% and 4.8%, respectively, with no structural valve deterioration. CONCLUSIONS: TAo-TAVR is feasible and safe with satisfactory midterm outcomes using both currently available devices.

Pain Trajectories After Valve Surgeries Performed via Midline Sternotomy Versus Mini-Thoracotomy.

OBJECTIVES: Controlling moderate-to-severe pain remains a major challenge after cardiothoracic surgery. Several outcomes have been compared extensively after valve surgery performed via midline sternotomy versus mini-thoracotomy, but postoperative pain (POP) was not adequately examined. Therefore, the authors tested the hypothesis that there is no difference in POP trajectories in patients undergoing valve surgery via midline sternotomy versus mini-thoracotomy. DESIGN: An Institutional Review Board-approved retrospective study. SETTING: At a single, large academic medical center. PARTICIPANTS: Adult patients who underwent mitral or aortic valve surgeries over a 5-year period. INTERVENTIONS: The authors compared the characteristics of pain between valve surgery patients receiving either midline sternotomy or mini-thoracotomy. To identify pain score trajectories, the authors employed latent class linear mixed models and then used multinomial regression models to study the association between incision type and pain trajectory class. MEASUREMENTS AND MAIN RESULTS: The authors' cohort consisted of 1,660 surgical patients-544 (33%) received a midline sternotomy, and 1,116 (66%) received a mini-thoracotomy. The authors identified the following 4 pain trajectory classes: stationary, rapidly improving, slowly improving, and acute worsening pain. Compared to the rapidly improving class, the odds of belonging to the stationary (adjusted odds ratio [aOR] [95% CI] 1.45 [1.01- 2.08]; p = 0.04) or the acute worsening class (aOR [95% CI] 1.71 [1.10-2.67] p = 0.02) were significantly higher for sternotomy patients compared to mini-thoracotomy. CONCLUSIONS: Midline sternotomies are associated with higher odds of having an acute worsening or stationary versus a rapidly improving pain trajectory compared to mini-thoracotomies. Therefore, the choice of incision may play an important role in determining POP trajectory after valve surgery.

Routine minimally invasive approach via left anterior mini-thoracotomy in multivessel coronary revascularization.

BACKGROUND: Minimally invasive heart surgery continues to spread rapidly around the world. Although coronary artery bypass surgery with median sternotomy continues to be performed intensively in many centers, the results of the new literature continue to contribute to proving the reliability of minimally invasive coronary surgery. In this study, we aimed to contribute to the routine feasibility of minimally invasive coronary bypass with left anterior mini-thoracotomy with our own case series. METHODS: From July 2019 to August 2021 a total of 184 nonselected consecutive patients underwent minimally invasive on-pump multivessel coronary artery bypass grafting through the left anterior minithoracotomy in the fourth intercostal space. In the operation decision; regardless of low ejection fraction, morbid obesity, number of diseased vessels, or other comorbid factors, bypass operation was performed routinely via thoracotomy without selecting patients, except redo patients or porcelain aorta. The mean number of grafts was 3.3 ± 0.5. Left internal mammary artery was used in all patients. For other anastomoses; saphenous vein graft was used. Cardiopulmonary bypass (CPB), aortic cross-clamping, and blood cardioplegia were used in all patients. Postoperative results of all patients were analyzed retrospectively. RESULTS: The total CPB time was 144.5 ± 27.3 min, and aortic cross-clamp time 82.1 ± 16.2 min. The mean intensive care stay was 1.2 ± 0.7 days and mean total hospital stay 5.1 ± 1.2 days. Total perioperative mortality was 0.54% (one patient). Myocardial infarction was not observed in any case in the postoperative period. The cause of mortality was delayed tamponade occurring on the fifth postoperative day. Nine patients underwent revision due to bleeding in the early postoperative period. There was no patient who underwent stroke or developed renal failure requiring hemodialysis in the postoperative period. One hundred and eighty-three patients (99.4%) were discharged with good recovery. CONCLUSION: Minimally invasive multivessel bypass surgery is a surgical method that has just started to become widespread. The fact that the technique is new and more challenging than conventional methods makes it difficult for surgeons to adopt it. In addition, one of the most important issues is that the surgical results should be satisfactory. Our study shows that safe, successful, and satisfactory results can be obtained by using this method, as in our case series. In addition, we think that it can be successfully applied routinely to all patients without distinction.

Surgery of the ascending aorta via a right anterior minithoracotomy: initial surgical experience of a single center.

OBJECTIVES: Full median sternotomy (FMS) is the common surgical access for patients undergoing replacement of the ascending aorta (AA) with or without aortic valve replacement (AVR). The right anterior mini-thoracotomy (RAMT) approach has been increasingly adopted for AVR. This approach has been shown to decrease blood loss and hospital length of stay (LOS) compared with FMS. The RAMT approach may also be beneficial in selected patients requiring AA procedures with or without AVR. We present our initial clinical experience of patients who have undergone a RAMT for supracommissural replacement of the tubular AA with or without AVR. METHODS: This is a single-center retrospective review of 10 patients who underwent an elective RAMT for replacement of the tubular AA with or without AVR between November 2019 and January 2022. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital LOS, time to extubation, operative times, as well as postoperative complications such as stroke and bleeding. RESULTS: Median cross-clamp and cardiopulmonary bypass times were 109 and 148 min, respectively. Median time to extubation was 2.5 h and median intensive care unit and hospital stay were 2 and 10 days, respectively. There were two re-thoracotomies for postoperative bleeding and two cases of sub-xiphoidal pericardial drainage for pericardial effusion. There were no strokes and no in-hospital nor 30-day mortalities. CONCLUSIONS: The replacement of the AA with or without concomitant AVR can be performed through a RAMT in carefully selected patients. However, the safety of this approach, as compared to full/partial median sternotomy, remains to be proven.

Key questions: Can ascending aorta surgery with or without aortic valve replacement be safely performed via right thoracotomy?Key Findings: A good experience of right thoracotomy approach helps performing ascending aorta surgery via that access in carefully selected patients.Take home message: Center with expertise in right thoracotomy can performed ascending aorta surgery through that access in carefully selected patients. However, the safety of this approach, as compared to full or partial median sternotomy, remains to be proven.

Upper Hemi-Sternotomy Provides Benefit for Patients with Isolated or Combined Mitral Valve Surgery.

Background and objectives: Certain clinical and anatomical conditions are absolute or relative contraindications for safe mitral valve surgery via the right mini-thoracotomy access. It is uncertain whether patients with these contraindications may benefit from the less invasive approach via upper hemi-sternotomy compared to standard full sternotomy. Materials and methods: Out of 2052 mitral valve surgery patients, operated from 6/04 through 2/19, 1535 were excluded due to the different criteria for eligibility to both approaches. Out of these, 350 received full sternotomy and 167 upper hemi-sternotomy. After propensity score matching, 164 pairs were analyzed for operative variables, postoperative complications and 30-day and one-year survival. Results: Upper hemi-sternotomy was associated with a survival benefit of 30 days (99.4% vs. 82.1%; p < 0.001) and one-year (93.9% vs. 79.9% p < 0.001, HR 0.26, 95% CI 0.14-0.49). Cardiopulmonary bypass and aortic cross-clamp times were comparable in both groups. Upper hemi-sternotomy resulted in less low cardiac output syndrome (18.9% vs. 31.1%; p = 0.011); ventilation time (8 vs. 13 h; p < 0.001), length of intensive care stay (1 vs. 2 days; p < 0.001) and total hospital stay (8 vs. 9 days; p < 0.001) were shorter in the upper hemi-sternotomy group. Conclusion: In patients undergoing mitral valve surgery, upper hemi-sternotomy is associated with short- and mid-term survival benefits as well as lower postoperative complication rates compared to full sternotomy. Hence, the less invasive upper hemi-sternotomy can be a valid approach in patients with contraindications for right mini-thoracotomy.

Minimal invasive approach of post-MI ventricular septal defect repair and coronary artery revascularization via left anterior minithoracotomy.

A 54-year-old male was admitted to our hospital with a prolonged dypsnea, orthopnoea, and chest pain that has lasted for almost 2 weeks. Physical examination revealed symptoms of heart failure. Transthoracic echocardiography revealed a ventricular septal defect located at the apical segment of the interventricular septum, mild mitral regurgitation, and hypokinesia of the apex of the left ventricle. Coronary angiography showed a critical proximal lesion of the left anterior descending artery. He was diagnosed with postmyocardial infarction ventricular septal defect. Our patient underwent minimal invasive coronary artery bypass and ventricular septal defect repair via left anterior minithoracotomy. Postoperative period was uneventful and our patient was released on a postoperative Day 7. Postoperative transthoracic echocardiography revealed no residue of repaired ventricular septal defect with improved left ventricular functions.

Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center.

OBJECTIVE: The goal of this manuscript was to report the clinical outcomes of the initial series of 100 consecutive Right Anterior Mini Thoracotomy (RAMT) aortic valve replacement (AVR) implantations at a Canadian Center. METHODS: This retrospective study reported the clinical outcomes of the first 100 patients who underwent the RAMT approach for isolated surgical AVR in Calgary, Canada, between 2016 and 2020. Primary outcomes were death within 30 days of surgery and disabling stroke. Secondary outcomes included surgical times, the need for permanent pacemaker (PPM), incidence of postoperative blood transfusion in the intensive care unit (ICU), postsurgical atrial fibrillation (AF), length of ICU/hospital stay, postsurgical AF, residual paravalvular leak (PVL), postoperative transvalvular gradient, need for postsurgical intravenous opioids, duration of invasive ventilation in the ICU, and chest tube output in the first 12 h postsurgery. RESULTS: In this study, 54 patients were male, and the average age of the cohort was 72 years. Mortality within 30 days of surgery was 1% with no disabling postoperative strokes. Mean cardiopulmonary bypass and cross clamp was 84 and 55 min, respectively. PPM rate was 3%, incidence of blood transfusion in the ICU was 4%, and the rate of postoperative AF was 23%. Median length of ICU and hospital stay was 1 and 5 days, respectively. Rate of mild or greater residual PVL was 3%, while the average residual transvalvular mean gradient was 8.5 mmHg. CONCLUSION: The sternum-sparing RAMT approach can be safely integrated into surgical practice as a minimally invasive alternative for isolated AVR, and can reduce postoperative bleeding and narcotic requirements.

[Prehospital treatment of tension pneumothorax in children-which decisions do we make? : Results of a survey among German emergency physicians]. / Die prähospitale Therapie eines Spannungspneumothorax bei Kindern ­ welche Entscheidungen treffen wir? : Ergebnisse einer Umfrage unter deutschen Notärzten.

BACKGROUND: The preclinical treatment of a traumatic or spontaneous tension pneumothorax remains a particular challenge in pediatric patients. Currently recommended interventions for decompression are either finger thoracostomy or needle decompression. Due to the tiny intercostal spaces, finger thoracostomy may not be feasible in small children and surgical preparation may be necessary. In needle decompression, the risk of injuring underlying vital structures is increased because of the smaller anatomic structures. As most emergency physicians do not regularly work in pediatric trauma care, decompression of tension pneumothorax is associated with significant uncertainty; however, in this rare emergency situation, consistent and goal-oriented action is mandatory and lifesaving. An assessment of pre-existing experience and commonly used techniques therefore seems necessary to deduce the need for future education and training. OBJECTIVE: In this study an online survey was created to evaluate the experience and the favored prehospital treatment of tension pneumothorax in children among German emergency physicians. MATERIAL AND METHODS: An online survey was conducted with 43 questions on previous experience with tension pneumothorax in children, favored decompression technique and anatomical structures in different age groups. Surveyed were the emergency physicians of the ground-based emergency medical service of the University Medical Center Mannheim, the German Air Rescue Service (DRF) and the pediatric emergency medical service of the City of Munich. RESULTS: More than half of all respondents stated that there was uncertainty about the procedure of choice. Needle decompression was favored in smaller children and mini-thoracostomy in older children. In comparison with the literature, the thickness of the chest wall was mostly estimated correctly by the emergency medical physicians. The depth of the vital structures was underestimated at most of the possible insertion sites in all age groups. At the lateral insertion sites on the left hemithorax, however, the distance to the left ventricle was overestimated. The caliber of the needle selected for decompression tended to be too large, especially in younger children. CONCLUSION: Even though having interviewed an experienced group of prehospital emergency physicians, the experience in decompression of tension pneumothorax in children is relatively scant. Knowledge of chest wall thickness and depth to vital structures is sufficient, the choice of needle calibers tends to be too large but still reasonable. For many providers a large amount of uncertainty about the right choice of technique and equipment arises from the challenge of decompressing a tension pneumothorax in children and therefore further theoretical education and regular training are required for safe performance of the procedure.

Alternate method for endocardial pacemaker lead implantation: A hybrid mini-thoracotomy approach.

Although the conventional methods for endo-cardial pacemaker lead implantation via subclavian or cephalic or axillary vein routes is common, but sometimes due to anatomical variations it is not feasible to access these veins Emergence of newer techniques are useful for lead implantation. This case report focuses on a hybrid approach of combined mini-thoracotomy for endocardial pacemaker lead implantation. This fluoroscopy guided minimal thoracotomy approach with endocardial MRI compatible lead placement had the benefits of simple procedural, minimal hospital stay, low early complication rates and economically viable to the patient.

[First serial transcatheter implantation of pulmonary valve using MedLab-KT prosthesis]. / Pervaia seriinaia transkateternaia implantatsiia klapana legochnoi arterii pri pomoshchi proteza (MedLab-KT).

BACKGROUND: Surgical treatment of 'blue' congenital heart defects frequently implies various interventions on the outlet portion of the right ventricle or pulmonary artery trunk. Most often used are various conduits, reconstructing the outlet portion of the right ventricle and pulmonary artery. Most patients having previously endured the mentioned interventions, would in the remote terms require repeat operative procedures for stenosis or insufficiency on the pulmonary valve or the implanted conduit. Taking into account complexity and the risk of open interventions, the current trends are towards more frequent use of transcatheter implantation of the pulmonary valve. AIM: The purpose of this work is to present the first serial experience with hybrid transventricular implantation of an original Russian-made valve into the position of the pulmonary artery. PATIENTS AND METHODS: We retrospectively studied a series of 5 clinical cases who from July 2019 to May 2020 at the Federal Centre of Cardiovascular Surgery (Penza) had underwent hybrid transventricular implantation of the first Russian-made valve-containing stent (MedLab-KT) into the position of the pulmonary valve, with the stent's closing component consisting of leaflets made of polytetrafluoroethylene. RESULTS: 3 patients underwent implantation of valve # 25 and 2 subjects received valve # 23, with all cases yielding good immediate results. The haemodynamic parameters of the implanted prosthesis were optimal. In all cases, the significant gradient was absent and regurgitation did not exceed grade I. There was no in-hospital mortality. The method of hybrid prosthetic repair of the pulmonary valve via the transapical right-ventricular access from the left lateral mini-thoracotomy was aimed at reducing potential risks of artificial circulation, also contributing to a significant decrease in the traumatic nature of surgical treatment of patients requiring a repeat intervention for pulmonary valve pathology.

Early and midterm results of minimally invasive aortic and mitral valve surgery via right mini-thoracotomy.

OBJECTIVES: There are few reports regarding minimally invasive aortic valve replacement concomitant with mitral valve surgery (MIAMVS). The aim of this study was to evaluate early and midterm MIAMVS results. METHODS: We reviewed the medical records of 21 consecutive patients (nine females, 43%) who underwent MIAMVS through a right mini-thoracotomy from December 2014 to April 2017. Mean patient age was 73 ± 7.4 years and four (19%) were New York Heart Association Class III or IV. Aortic stenosis and mitral valve insufficiency were the most common pathologies. All patients were followed for a mean period of 30 ± 8.5 months. RESULTS: The types of surgery consisted of aortic valve replacement with mitral valve repair in 11 (52%) patients, and replacement of both aortic and mitral valves in 10 (48%), while a tricuspid valve repair, was performed in four. No conversion to a full sternotomy was necessary in any of the cases. Postoperatively, the median intensive care unit and hospital stays were 4.7 and 11.8 days, respectively, with no in-hospital mortality. Following the initial treatment, all 21 patients were followed for a mean period of 30 ± 8.5 months (14-45 months). All patients returned to NYHA Class I or II following the procedure. During the follow-up period, there was no need for a heart valve reoperation for any of the patients and none showed recurrent mitral regurgitation (>mild), though one died from respiratory failure caused by pneumonia. CONCLUSIONS: MIAMVS can be performed via a right mini-thoracotomy, with acceptable early and midterm results expected. This may be a feasible alternative to the standard median sternotomy approach.

[Sinus septal defect closure with correction of partial anomalous pulmonary vein drainage through mini-thoracotomy]. / Plastika sinus septum defekta s korrektsiei chastichnogo anomal'nogo drenazha legochnykh ven iz minitorakotomnogo dostupa.

Mini-thoracotomy is one of the most popular minimally invasive approaches. This approach is used in the treatment of congenital and acquired heart diseases and characterized less surgical trauma, intraoperative blood loss, pain syndrome severity, risk of infectious complications and better cosmetic results. Successful correction of atrial septal defect (ASD) through right-sided mini-thoracotomy is reported in the article.

Minimally Invasive Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: Propensity Matched Initial Experience.

BACKGROUND: Aortic valve replacement by way of a right anterior mini-thoracotomy (RAMT) has shown excellent results in terms of mortality and morbidity. The aim of the present study was to compare RAMT aortic valve replacement (AVR) with conventional full sternotomy in regards to early perioperative outcomes and mortality. METHODS: This was a retrospective, observational, cohort study of prospectively collected data from patients who underwent isolated, first time AVR between January 2013 and October 2016. Fifty-three RAMT patients were matched to a control group (conventional full sternotomy) using propensity score analysis. RESULTS: The characteristics of the two cohorts were similar. The in-hospital mortality was 1.9% utilising the RAMT approach versus 5.7% using the sternotomy approach (p=0.34). Ventilation times were similar in both groups (7 [5-2] vs 8 [5-13] hrs; p=0.61). However, ICU length of stay was significantly longer in the RAMT group (median, 46.5 [23-59.5] vs 20 [14-23] hrs; p<0.001), which translated into a significantly longer postoperative hospital length of stay for the RAMT group (median, 8 [6-12] vs 6 [5.5-9.5] days; p=0.04) compared to the sternotomy group. RAMT was associated with a trend towards a higher incidence of postoperative AF in comparison to the sternotomy group, although this was not statistically significant (41.5% vs 28.3%; p=0.17). Patients in the RAMT group had lower 4-hour chest drain output (102.5 vs 1141ml; p=0.0.07). There was no statistically significant difference in rates of non-red cell transfusions between the two groups, (17%vs28.3%; p=0.10). The occurrence of stroke, re-exploration for bleeding, red-cell transfusion and wound infection was similar in both groups. CONCLUSIONS: Right anterior mini-thoracotomy in patients undergoing isolated aortic valve surgery is a safe approach in select patients, although associated with longer cardiopulmonary bypass times and ICU length of stay.

Safety and benefits of new techniques and technologies in less invasive mitral valve repair.

OBJECTIVE: To assess the safety and benefits of new techniques and technologies such as single-dose (del Nido) cardioplegia and suture fasteners (COR-KNOT) in patients undergoing mini-thoracotomy for degenerative mitral valve repair (MVR). METHODS: From 2009 to 2016, 252 patients underwent primary isolated degenerative MVR by mini-thoracotomy by a single surgeon. Del Nido cardioplegia was used in 153 patients (61%) and COR-KNOT in 168 (67%). Patient outcomes were compared using propensity-matching separately for del Nido versus Buckberg cardioplegia and COR-KNOT versus knot-pusher. RESULTS: There were no operative deaths and 99.2% of the patients had none/trivial mitral regurgitation at discharge. In patients receiving del Nido or Buckberg cardioplegia, occurrence of adverse events was similar. However, aortic cross clamp (AoCC; 54.2 ± 15.7 vs 64 ± 15.8 min; P < 0.0001) and operative room (OR; 308 ± 42.1 vs 336 ± 63 min; P < 0.001) times were shorter with del Nido cardioplegia. In patients receiving COR-KNOT versus knot-pusher, occurrence of adverse events was similar. However, AoCC (54.1 ± 15.2 vs 66.1 ± 15.9 min; P < 0.0001) and OR (311 ± 43.6 vs 336 ± 65.4 min; P < 0.0001) times were shorter with COR-KNOT. Results were similar after matching for both, del Nido versus Buckberg cardioplegia and COR-KNOT versus knot-pusher. CONCLUSION: New techniques and technologies, such as del Nido cardioplegia and COR-KNOT, decrease AoCC and OR times without compromising patient safety.