Anterolateral Minithoracotomy Research Articles

Clamp Ablation of Pulmonary Veins During Minimally Invasive Aortic Valve Replacement

Here, we demonstrate bilateral pulmonary vein isolation using a bipolar clamp but without atriotomy during minimally invasive aortic valve replacement. The operation was performed through a right anterolateral minithoracotomy. The right pulmonary veins were ablated by using a radiofrequency clamp on the beating heart. After cardiac arrest, the ascending aorta was pulled up using umbilical tape passed through the transverse sinus. Appendage resection offered fine exposure around the lower pulmonary vein. The bipolar clamp was introduced into the oblique sinus under the aorta, and the left pulmonary veins were ablated. Finally, aortic valve replacement was performed in a standard manner.

Minimally Invasive Mitral Valve Surgery for Mitral Valve Infective Endocarditis.

The feasibility of minimally invasive mitral valve (MV) surgery in infective endocarditis (IE) has not been reported in detail. We assessed the safety, efficacy, and durability of the minimally invasive approach through a right anterolateral minithoracotomy for surgical treatment of MV IE. A review of the Leipzig Heart Center database revealed 92 eligible patients operated on between 2002 and 2013. All patients had undergone minimally invasive surgery for IE. The indication for surgery was isolated IE of the MV in all patients. Baseline and intraoperative data, as well as clinical outcomes and short-term follow-up were analyzed retrospectively. The patients' mean age was 60.9 ± 15.3 years, the logistic EuroSCORE II was 19.6 ± 19.1%, and 64.1% (59) were male. MV repair was feasible in 23.9% (22/92) of patients. Repair techniques included annuloplasty ring implantation, anterior mitral leaflet resection, posterior mitral leaflet resection, and implantation of neochordae. MV replacement was performed in 69 patients (75%), a mitral annulus patch in 1 patient, and concomitant tricuspid valve surgery for tricuspid regurgitation in 5 patients. Bacteriological analysis showed staphylococcus infection in 45.5%, streptococcus in 36.4%, enterococcus in 13.6%, and others in 4.5%. The 30-day-mortality rate was 9.8% (9 patients). The 1-year follow-up showed a 1-year survival rate of 77.7 ± 4.4% and freedom from reoperation within 1 year due to reendocarditis of 93.3 ± 2.1%. The minimally invasive approach is suitable for the treatment of IE of the MV. It is a good technique in IE in selected patients.

Benefits of a right anterolateral minithoracotomy rather than a median sternotomy in isolated tricuspid redo procedures.

To compare results of tricuspid valve (TV) reoperation between incision via a right anterolateral minithoracotomy (RAMT) and median sternotomy (MS). We performed a retrospective analysis of 49 patients who underwent isolated TV surgery as a reoperation at our institution between 2006 and 2015. Previous cardiac operations included mitral, aortic, and TV surgeries, atrial septal defect repair, and pericardiectomy. The mean age of the patients was 51.9±12.8 years, 14 (28%) were male and 35 (72%) were female. Follow-up was 95% (38/40) complete, with a mean duration of 41.3±19.5 months. Perioperative demographic and laboratory tests did not show any significant differences between the RAMT and MS groups. The drainage volume, total red cell unit, total serum volume and platelet were significantly different 1150±803.5/2,270±1,920, 4.8±4.1/8.7±8.9, 478.2±488.9/950.0±857.6, 0.04±0.21/0.38±0.64 (P<0.05), while other perioperative data were similar. There were no significant differences in early postoperative death and complications between the RAMT and MS groups. A multivariate linear regression analysis predicted that serum creatinine (Scr), age, and MS group were independent risk factors for bleeding. The Cox regression demonstrated that the MS group had a longer drainage duration (P<0.05) and had a relative hazardous risk (HR) of 2.691 (1.328, 5.450 CI) compared with the RAMT group. The RAMT approach is an alternative, safe, and feasible procedure for isolated TV reoperation. It has the advantages of less drainage and reduced requirement for blood products.

Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement

Propensity score-matched analysis of the anterolateral minithoracotomy and the partial upper hemisternotomy vs the median sternotomy approach has not been reported to date for isolated aortic valve replacement. From 2005 to 2013, isolated aortic valve replacement was performed through a partial upper hemisternotomy in 315 patients (38.9%), through a median sternotomy in 328 patients (40.5%), and through an anterolateral minithoracotomy in 167 patients (20.6%). After propensity score-matched analysis, both minimally invasive techniques were independently compared with median sternotomy in 118 matched pairs. In the anterolateral group, conversion to median sternotomy was significantly higher (17 [14.4%]), a second pump run (6 [5.1%]) and second cross clamp (12 [10.2%]) were significantly more often necessary, the median cross-clamp time (94 minutes; range, 43 to 231 minutes) and median perfusion time (141 minutes; range, 77 to 456 minutes) were significantly longer, and more groin complications occurred (17 [14.4%]), all compared with the median sternotomy group. No difference in perioperative results was identified between the partial upper hemisternotomy and the median sternotomy group. There was no significant difference in 1-year survival among the three groups, although a trend of better survival was observed in the partial upper hemisternotomy group. In minimally invasive isolated aortic valve replacement, the partial upper hemisternotomy shows similar perioperative outcome as the median sternotomy, whereas, the anterolateral minithoracotomy is associated with more perioperative complications. Therefore, only the partial upper hemisternotomy should be the preferred surgical technique for minimally invasive aortic valve replacement in the daily routine for a broad spectrum of surgeons.

Outcome variables of right anterolateral mini-thoracotomy versus complete sternotomy in atrial septal defect closure: A randomized controlled trial

BackgroundOver the last decades, atrial septal defect repair (ASD) as one of the most congenital anomalies has been customarily repaired via sternotomy incision. This technique is associated with very low operative risks and excellent outcomes but with poor esthetic results for the patients. Consequently, right anterolateral mini thoracotomy was invented as a substitute technique aiming for superior cosmetic results. Our study aim was to compare the perioperative outcomes for different approaches. MethodsForty patients (15 males, 25 females) with ASDs were randomly assigned to have either one of these two approaches at our institution from March 2013 until May 2016. The patients' ages ranged from 2 to 53 years old. Based on their randomization, group I (20 patients), had right anterolateral mini-thoracotomy (RALT) and group II (20 patients) who had sternotomy for surgical closure of ASD. We collected the different demographic, baseline, perioperative and postoperative characteristics. ResultsThe patients in both groups were similar in age preoperative comorbidities and ejection fraction but more females were in RALT group. There was a highly statistically significant prolonged pump-run time in the thoracotomy group than the sternotomy group with p-value = 0.004. Interestingly, in the thoracotomy group, mechanical ventilation time (hours) was shorter with p-value = 0.002. There were similar blood transfusion rate, chest tube drainage, intensive care unit stay and hospital length of stay. However, more wound infection was found in the sternotomy group which was statistically significant (p-value = 0.035). There were no patients requiring conversion to full sternotomy, no residual defect across the atrial septum and all patients were alive on a month follow-up of the hospital discharge. ConclusionsRight anterolateral mini-thoracotomy is safe, cosmetic, effective and technically feasible and not inferior to the formal median sternotomy to repair ASDs surgically.

Apical closure device for full-percutaneous transapical valve implantation: stress-test in an animal model†.

Transapical valve implantation is traditionally performed through a left antero-lateral mini-thoracotomy. A self-expandable apical closure device has recently been developed for full-percutaneous transapical valve implantation. We performed haemodynamics stress-tests on an animal model to evaluate the sealing properties. Under general anaesthesia 5 pigs (mean weight: 67 ± 6 Kg) received full heparinization (100 IU/Kg; activated clotting time >250 s and, through inferior mini-sternotomies, 21-Fr introducer sheaths for transapical aortic valve implantation (outer diameter: 25-Fr) were placed over-the-wire in the apexes. Delivery-catheters carrying folded occluders (SAFEX TM final design) were inserted in the introducer sheaths and plugs were then deployed under fluoroscopic guidance. Phase 1: after protamine injection, apical bleeding was monitored for 1 h with standard haemodynamics condition. Phase 2: we induced systemic hypertension with adrenaline infusion to test the sealing properties under stress. Animals were sacrificed after Phase 2 and hearts were removed and inspected. Five plugs were successfully introduced and deployed in 5 pig hearts. Plugs provided good apical sealing in each animal and a mean of 7 ± 4 ml of blood lost per animal was collected during Phase 1: haemodynamics remained stable and no plug dislodgement was detected (mean blood pressure: 52 ± 9 mmHg). During Phase 2, mean systolic and diastolic peak levels reached 268 ± 24 mmHg and 175 ± 17 mmHg, respectively, without plug dislodgment or bleeding. Post-mortem inspection showed good plug deployment and fixation without myocardial damage. The new apical occluder seals large-sized apical access sites in animal models also during induced systemic hypertension. This pilot study is a further step towards full-percutaneous transapical valve procedures in the clinical setting.

Minimally Invasive Mitral Valve Surgery: An Update

Minimally invasive mitral valve surgery (MIMVS) was introduced in the mid-1990s to refer to a variety of surgical techniques that avoid full sternotomy through smaller or alternative chest wall incisions, as an attempt to reduce complications, but at the same time preserve outcomes of the full sternotomy approach. In this review, different aspects of MIMVS are discussed in relation to its approaches (right parasternal incision, lower ministernotomy, right anterolateral minithoracotomy and left posterior minithoracotomy) as well as strategies (mini-incisions, video-assistance, video direction with robotic assistance and telemanipulation) passing through more than 2 decades of continuous evolution. In the current practice MIMVS shows similar outcome to conventional surgery with even more superior results regarding blood loss, ICU and hospital stay, as well as functional recovery. The accumulating experience with MIMVS encouraged surgeons to extend the application of these techniques to high-risk patients, redo surgeries, concomitant double or triple valve procedures as well as combined coronary artery and mitral valve diseases in a hybrid approach, reducing the need for full median sternotomy. In addition there is an emerging trend of transcatheter valve implantation in the mitral position with small reports of valve-in valve or valve-in- ring implantation as well as valve replacement in case of severe MAC. This new trend may establish itself in the future as a modality in treating native mitral valve diseases in high risk patients. Therefore it is recommended for cardiac centers to build up a program for MIMVS in order to fulfill the recent requirements of cardiac surgery.

Anterior Minithoracotomy: a Safe Approach for Surgical ASD Closure & ASD Device Retrieval.

ObjectiveMidline sternotomy is the preferred approach for device migration following transcatheter device closure of ostium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect.MethodsAmong the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy.ResultsTwelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic cross-clamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication.ConclusionMinithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.

Early post-operative pulmonary function tests after mitral valve replacement: Minimally invasive versus conventional approach. Which is better?

BackgroundMinimally invasive mitral valve surgery (MIMVS) is safe, with low perioperative morbidity, and low rates of reoperation. Minimally invasive mitral valve surgery has been proven a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Efforts to minimize surgical trauma, fasten patient recovery, increase patient satisfaction, and reduce cost without compromise to surgical repair or replacement techniques, continue to be the rationale for minimally invasive procedures. In this work, the difference in pulmonary function tests between both approaches was studied among other variables. MethodsIn this study 50 patients with mitral valve disease (MVD) requiring mitral valve surgery were selected by purposive nonprobability sample. The study was done at the Armed Forces Hospitals (mainly Maadi & Galaa Armed Forces Hospitals). 25 patients attended to have mitral valve surgery by right anterolateral mini-thoracotomy (group A) with femoral artery and vein cannulation and other 25 patients by traditional sternotomy (group B). Pulmonary function tests were studied within one week preoperatively and 10 days postoperatively in both groups. ResultsThere was no statistical difference between the two groups preoperatively regarding their age, sex, NYHA class, EF%, LA dimension, and preoperative spirometric study. There was no operative mortality in both groups but fewer postoperative complications occurred in both groups with highly significant differences in favor of minimal invasive group. These included better postoperative pulmonary function tests. There was a highly significant difference in the FVC, FEV1, FVC %, FEV1 % and no significant change in FEV1/FVC between both group denoting better post operative pulmonary function of minimally invasive (group A) patients. There was also less blood loss, less postoperative blood transfusion, less total hospital stay, ICU stay, faster recovery with better cosmetic appearance, and more cost effective. ConclusionMinimally invasive right anterolateral mini-thoracotomy is as safe as median sternotomy for mitral valve surgery, with fewer complications and postoperative pain, less ICU and hospital stay, fast recovery to work with no movement restriction after surgery. There was a highly significant difference denoting better post operative pulmonary function of the minimally invasive approach.

Hybrid approach to multivessel coronary artery disease: a commentary.

Hybrid coronary revascularization (HCR) intends to combine the advantages of both minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI). Thus, HCR is a sternal-sparing, off-pump, minimally invasive, hand-sewn left internal mammary artery (LIMA) to left anterior descending (LAD) bypass graft though a 4–6 cm anterolateral minithoracotomy with PCI to non-LAD lesions, in order to achieve a functional complete revascularization. HCR should, in theory, provide the perfect revascularization: stents replace the need for the saphenous vein graft (SVG), and MIDCAB provides a minimally invasive approach to reduce surgical morbidity.

Early outcome of minimally invasive mitral valve surgery

BackgroundMinimally invasive mitral valve surgery (MIMVS) is safe, with low perioperative morbidity, and low rates of reoperation. Minimally invasive mitral valve surgery has been proven a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Efforts to minimize surgical trauma, hasten patient recovery, increase patient satisfaction, and reduce cost without compromise to surgical repair or replacement techniques, continue to be the rationale for minimally invasive procedures. MethodsIn this study 30 patients with mitral valve disease (MVD) requiring mitral valve surgery selected by purposive non probability sample. The study was done at the Armed Forces Hospitals (mainly Maadi & Galaa Armed Forces Hospitals). 15 patients attended to do mitral valve surgery by traditional sternotomy (group B), other 15 patients by less invasive surgery (Rt. anterolateral mini-thoracotomy) (group A) with femoral artery and vein cannulation. ResultsThere was no statistical difference between the two groups preoperatively regarding their age, sex, NYHA class, EF%, LA dimension, spirometric study. There was no operative mortality in both groups but fewer postoperative complications occurred in both groups. Total hospital stay, ICU stay, postoperative bleeding, inotropic requirement, ventilatory support, blood transfusion was less in group “A”, with better cosmetic appearance, and more cost effective. ConclusionRight anterolateral mini-thoracotomy minimally invasive technique provides excellent exposure of the mitral valve, even with a small atrium and offers a better cosmetic lateral scar which is less prone to keloid formation. In addition, minimally invasive right anterolateral mini-thoracotomy is as safe as median sternotomy for mitral valve surgery, with fewer complications and postoperative pain, less ICU and hospital stay, fast recovery to work with no movement restriction after surgery. It should be used as an initial approach for mitral valve surgery. Furthermore, it was believed that less spreading of the incision, no interference with the diaphragm and less tissue dissection might improve outcomes, particularly respiratory function.

3. Early outcomes of minimally invasive versus conventional mitral valve surgery in mitral valve diseases. A single institutional experience

Minimally invasive techniques in cardiac surgery gained popularity due to many advantages like less postoperative pain, minimal blood loss, less hospital stay, less cost. Minimally invasive mitral valve surgery through right anterolateral mini thoracotomy became safe technique. In our study we compared mini-MV surgery with conventional technique regarding cross clamp time, bypass time, total blood loss, reopening for bleeding, and hospital and ICU length of stay. In our institution between 2010 and 2015, 147 patients underwent minimally invasive mitral surgery through right lateral minithoracotomy 8 cm incision and 118 patient underwent conventional mitral valve surgery through median sternotomy in minimally invasive technique: mean age was 38 ± 20 vs 59 ± 21, 70.7% were female ( n = 104) vs 39.8% ( n = 47), 23.8% were associated with tricuspid valve regurgitation ( n = 33) vs 55% in conventional technique ( n = 65), 0.08% were able to use endovascular clamp ( n = 12), mean Euroscore predected risk of mortality 14.7 ± 13.6% vs 8.7 ± 10.9%. Minimally invasive mitral valve repair surgery was accomplished in 77.5% ( n = 114) vs 46.15% ( n = 55 ) and replacement of mitral valve in 22.4% ( n = 30) vs 53.8% ( n = 64 ), concomitant procedures consists of tricuspid valve surgery in 23.8% ( n = 35) vs 55% ( n = 65), primary mitral valve repair included implantation of rigid annuloplasty ring in 79.6% vs 38.9% ( n = 46), duration of cardiopulmonary bypass in minimally invasive surgery was 123 ± 64 min vs 116 ± 62 min, cross clamp time was 64 ± 27 min vs 59 ± 23 min, postoperative mechanical ventilation time 4 ± 1.5 h vs 6.5 ± 2 h, ICU lenght of stay (LOS) was 48 ± 12 h vs 3 ± 1 days. Minimally invasive mitral surgery can be performed very safely with excellent early results. mini-MV surgery can be performed with a reasonable operative time, good perioperative course with decrease in postoperative ICU and hospital LOS.

Apical access and closure devices for transapical transcatheter heart valve procedures.

The majority of transcatheter aortic valve implantations, structural heart procedures and the newly developed transcatheter mitral valve repair and replacement are traditionally performed either through a transfemoral or a transapical access site, depending on the presence of severe peripheral vascular disease or anatomic limitations. The transapical approach, which carries specific advantages related to its antegrade nature and the short distance between the introduction site and the cardiac target, is traditionally performed through a left anterolateral mini-thoracotomy and requires rib retractors, soft tissue retractors and reinforced apical sutures to secure, at first, the left ventricular apex for the introduction of the stent-valve delivery systems and then to seal the access site at the end of the procedure. However, despite the advent of low-profile apical sheaths and newly designed delivery systems, the apical approach represents a challenge for the surgeon, as it has the risk of apical tear, life-threatening apical bleeding, myocardial damage, coronary damage and infections. Last but not least, the use of large-calibre stent-valve delivery systems and devices through standard mini-thoracotomies compromises any attempt to perform transapical transcatheter structural heart procedures entirely percutaneously, as happens with the transfemoral access site, or via a thoracoscopic or a miniaturised video-assisted percutaneous technique. During the past few years, prototypes of apical access and closure devices for transapical heart valve procedures have been developed and tested to make this standardised successful procedure easier. Some of them represent an important step towards the development of truly percutaneous transcatheter transapical heart valve procedures in the clinical setting.

Transaortic transcatheter aortic valve replacement through a right minithoracotomy with the balloon-expandable Sapien 3 valve.

Transaortic transcatheter aortic valve replacement performed through a right anterolateral minithoracotomy at the second intercostal space is a safe and standardized minimally invasive procedure carrying important clinical advantages for the patient, in particular, no damage to the ventricular apex, preservation of the diseased peripheral arteries and no cross of the aortic arch with the delivery system, meaning a lower risk of calcium dislodgement and neurological complications. Using the third-generation, balloon-expandable Edwards Sapien™ 3 transcatheter heart valve and the Certitude™ delivery system, the transaortic procedure is easily performed under fluoroscopic and echocardiographic guidance. Compared with the transapical procedure, the transaortic technique requires an inversely mounted stent valve and follows the standard guidelines for valve positioning and deployment under rapid pacing. The transaortic approach through a right anterolateral minithoracotomy at the second intercostal space combines the positive aspects of both transfemoral and transapical valve replacements without the risks of either procedure (left ventricular, coronary and peripheral vascular injuries).

Minimally Invasive Mitral Valve Surgery via Mini-Thoracotomy: Current Update.

In recent years, minimally invasive mitral valve surgery (MIMVS) has established itself as an alternative and increasingly used option for patients with mitral valve (MV) pathology. MIMVS is associated with a very low perioperative morbidity and mortality rate in appropriately selected patients, comparable to a full sternotomy approach. Besides superior cosmetic results, patients after MIMVS enjoy shorter recovery times and earlier returns to full activity. A number of approaches are branded as minimally invasive, but the most widely used one entails peripheral cardiopulmonary bypass and a small right anterolateral mini-thoracotomy. The operative technique and outcomes of this approach are summarized in the current update.

Invited Commentary

Invited Commentary

Comparison of Anterolateral Minithoracotomy Versus Partial Upper Hemisternotomy in Aortic Valve Replacement

In aortic valve replacement, a comparison between the anterolateral minithoracotomy and the partial upper hemisternotomy approach has not been reported to date. From 2006 to 2012, isolated aortic valve replacement was performed in 1,118 consecutive patients. Aortic valve replacement was performed through a anterolateral minithoracotomy in 166 patients (14.9%) and through a partial upper hemisternotomy in 245 patients (21.9%). A propensity score-matched analysis was performed in 160 matched pairs. Conversion to median sternotomy was significantly higher in the anterolateral group (n = 22, 13.1%) than in the hemisternotomy group (n = 7, 4.4%) (p = 0.004). A second cross-clamp was significantly more often necessary in the anterolateral group (n = 14, 8.8%) than in the hemisternotomy group (n =2, 1.3%) (p = 0.003). The median cross-clamp time was significantly longer in the anterolateral group, 93 minutes (range, 43 to 231 minutes) than in the hemisternotomy group, 75 minutes (range, 46 to 137 minutes) (p < 0.0001). The median perfusion time was significantly longer in the anterolateral group, 137 minutes (range, 81 to 456 minutes) than in the hemisternotomy group, 113 minutes (range, 66 to 257 minutes) (p < 0.0001). Significantly more groin adverse events occurred in the anterolateral group (n = 17, 10.8%) than in the hemisternotomy group (n = 0, 0%) (p < 0.0001). No significant difference in 90-day mortality was seen in the anterolateral group (n = 6, 3.8%) than in the hemisternotomy group (n = 2, 1.3%) (p = 0.16). The anterolateral minithoracotomy is associated with more perioperative adverse events. The partial upper hemisternotomy is an excellent surgical technique for minimally invasive aortic valve replacement in the daily routine for every staff surgeon.

Very High Repair Rate Using Minimally Invasive Surgery for the Treatment of Degenerative Mitral Insufficiency

BackgroundMinimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes. MethodsBetween May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete. ResultsThe mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively. ConclusionsA very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.

Transapical closure of paraprosthetic mitral leak in a patient with inferior vena cava interruption and azygos continuation

Para-valvular leaks represent a relevant post-operative complication of cardiac valve replacement, often causing heart failure or severe hemolysis. We report a case of a 72 year-old woman with aortic and mitral mechanical prostheses who developed hemolytic anemia because of a para-prosthetic mitral leak. Chest tomography in such patient unexpectedly documented inferior vena cava interruption with azygos continuation into superior vena cava. Given the high surgical risk, the venous anomaly and the presence of the aortic valve prosthesis, transcatheter leak closure via antero-lateral mini-thoracotomy and transapical approach was performed.

What Is the Best Surgical Approach for Bilateral Pulmonary Hydatid Cysts in Children?

Introduction: The most common site for hydatid cysts in children is the lungs while in adult hepatic cysts are predominant. Bilateral pulmonary involvement is relatively rare and its surgical management is poorly described in the current literature. Until now no definite consensus has been described in the literature for the ideal surgical approach in pediatric bilateral pulmonary hydatid cysts (BPHC). The aim of this prospective cohort study was to describe the problems encountered in treating pediatric BPHC by two different surgical techniques. Patients and Methods: Between June 2007 and June 2014, 60 children (group one = 31, group two = 29) with BPHC were operated on in our center. Group one included all children with BPHC operated by single session bilateral anterolateral mini-thoracotomy. Group two included all cases operated by two stage standard posterolateral thoracotomy at 21 days interval. Results: In group one (19 males and 12 females), the mean age was 8.9 years (3.5 - 17). In group two, there were 29 cases (18 males and 11 females), the mean age was 9.6 years (2 - 17). There was no significant statistical difference in terms of the presentations and age distribution. The duration of surgery in group one was significantly shorter and the duration of hospital stay was significantly shorter as well (group one 3.6 days versus 4.6 days in the second group). Pain scale was not more in the first group as it was believed to be. Conclusion: We believe that single session bilateral anterolateral thoracotomy is a better approach than either one stage successive thoracotomies, median sternotomy or clamshell thoracotomy as it involves less postoperative pain and does not precipitate a decrease in the respiratory capacity.