Left Anterolateral Minithoracotomy Research Articles

Retrospective Study on Anterolateral Mini-Thoracotomy in Emergency Surgical Drainage for Massive Pericardial Effusion Including Sternotomy Case

Background: The conventional method for managing the surgical drainage of an acute massive pericardial effusion typically involves a median sternotomy. Nevertheless, advancements in surgical optics and tools have enabled the utilization of progressively smaller incisions, such as a left anterolateral thoracotomy, for the same purpose. Aim of the Study: This study aimed to assess the surgical outcomes of left anterolateral mini-thoracotomy compared to median sternotomy for draining acute massive pericardial effusion. Methods: This research took place in the Cardiac Surgery Department at Ibrahim Cardiac and Research Institute, following approval from the local ethics committee, from June 2021 to June 2023. Fourteen patients with acute massive pericardial effusion necessitating emergency surgical drainage were included. The investigation concentrated on evaluating operative and short-term postoperative results to gauge the influence of two surgical drainage methods on patients' quality of life. Result: Both groups exhibited similar age, preoperative comorbidities, and ejection fraction. The sternotomy group required more operation time than the left anterolateral mini-thoracotomy group. Furthermore, the sternotomy group had a prolonged stay in the intensive care unit and hospital compared to the left anterolateral mini-thoracotomy group. Similar rates were observed for blood transfusion and chest tube drainage. However, two cases of superficial wound infection occurred in the sternotomy group. In the anterolateral thoracotomy group, no patients required conversion to full sternotomy, and all patients were alive at the one-month follow-up after hospital discharge. Conclusion: Employing a left anterolateral mini-thoracotomy for draining acute massive pericardial effusion was deemed a secure and reliable alternative to the traditional median sternotomy incision. Despite its limited operating field, requiring proficiency, this approach preserved sternal integrity, offered a more aesthetically pleasing incision, reduced the risk of wound infection, and decreased the need for analgesia. Additionally, it was associated with a faster recovery process and a shorter stay in the intensive care unit (ICU). (Bangladesh Heart Journal 2024; 39(2): 161-167

Simultaneous Minimally Invasive Coronary Artery Bypass Grafting and Lung Resection.

The best surgical treatment strategy for coexisting coronary artery disease (CAD) and lung cancer (LC) remains controversial. This study analyzed the safety and efficacy of a simultaneous minimally invasive procedure for patients with CAD and LC. Patients who underwent simultaneous minimally invasive off-pump coronary artery bypass grafting and lung resection from January 2016 to December 2021 were retrospectively analyzed. The procedure was performed in the fourth intercostal space through a small left anterolateral minithoracotomy. Harvesting of the left internal mammary artery (LIMA) and sewing of the anastomoses were performed under direct vision. Lung resections were performed with or without the assistance of a thoracoscope. Sixteen patients were included with a mean age of 67.13 ± 10.61 years. Procedural success occurred in all patients with a mean operative time of 366.88 ± 94.48 minutes. All patients received at least one coronary artery bypass LIMA graft. Pneumonectomy, lobectomy, segment resection, and wedge resection were performed in one (6.25%), eight (50%), two (12.5%), and five (31.25%) patients, respectively. There were no perioperative deaths or new myocardial infarctions. Complications included one case of postoperative bleeding, two lung infections, two cases of atelectasis, one case of pleural effusion, and one case of cardiac arrhythmia. All the patients were followed up for 1 to 57 months, cancer recurrence occurred in two patients, and one patient died. The remaining patients showed no evidence of tumor recurrence or myocardial infarction. This simultaneous minimally invasive procedure is safe and effective for selected patients with CAD and LC.

The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers.

Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease. It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy. Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9. Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.

Transcatheter Pulmonary Valve Replacement from Autologous Pericardium with a Self-Expandable Nitinol Stent in an Adult Sheep Model.

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow tract or bioprosthetic valve dysfunction, with excellent early and late clinical outcomes. However, clinical challenges such as stented heart valve deterioration, coronary occlusion, endocarditis, and other complications must be addressed for lifetime application, particularly in pediatric patients. To facilitate the development of a lifelong solution for patients, transcatheter autologous pulmonary valve replacement was performed in an adult sheep model. The autologous pericardium was harvested from the sheep via left anterolateral minithoracotomy under general anesthesia with ventilation. The pericardium was placed on a 3D shaping heart valve model for non-toxic cross-linking for 2 days and 21 h. Intracardiac echocardiography (ICE) and angiography were performed to assess the position, morphology, function, and dimensions of the native pulmonary valve (NPV). After trimming, the crosslinked pericardium was sewn onto a self-expandable Nitinol stent and crimped into a self-designed delivery system. The autologous pulmonary valve (APV) was implanted at the NPV position via left jugular vein catheterization. ICE and angiography were repeated to evaluate the position, morphology, function, and dimensions of the APV. An APV was successfully implanted insheep J. In this paper, sheep J was selected to obtain representative results. A 30 mm APV with a Nitinol stent was accurately implanted at the NPV position without any significant hemodynamic change. There was no paravalvular leak, no new pulmonary valve insufficiency, or stented pulmonary valve migration. This study demonstrated the feasibility and safety, in a long-time follow-up, of developing an APV for implantation at the NPV position with a self-expandable Nitinol stent via jugular vein catheterization in an adult sheep model.

Can Minimally Invasive Multivessel Coronary Revascularization Be a Routine Approach?

Advancement in the field of cardiovascular surgery has emerged with various minimally invasive approaches for the treatment of multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. This study describes our routine technical approach and clinical experience of minimally invasive coronary artery bypass via left anterior minithoracotomy for the treatment of patients with multivessel coronary lesions. Our experience includes 100 consecutive patients who were operated between July 2020 and April 2021. The left internal thoracic artery was harvested in all patients. Radial arterial grafts and saphenous vein grafts were harvested endoscopically. Patients were operated either under cardiopulmonary bypass (CPB) with blood cardioplegia through left anterior minithoracotomy of 5 to 7 cm or off-pump via left anterolateral minithoracotomy. We had single mortality (1%), no early postoperative myocardial infarction was observed. None of our patients was converted to sternotomy (0%). The mean number of bypass was 3.1 ± 0.8, the mean cross-clamping time was 78.1 ± 20.6 minutes, the mean CPB time was 153.2 ± 37.5 minutes, the average intubation time was 6.33 ± 11.29 hours, the mean intensive care unit stay was 1.62 ± 1.78 days, the mean hospital stay was 4.98 ± 3.01 days, the average total operation time was 4.20 ± 0.92 hours, and the average pleural drain was 393.8 ± 169.7 mL. Minimally invasive coronary artery bypass grafting via left anterior minithoracotomy can be routinely performed with safety and it is feasible, reproducible with a short learning curve. Further multicenter studies are needed for the standardization of our technique.

First results of a regenerative transcatheter heart valve implant from autologous tissue in a long-term animal model

Abstract Background The perfect heart valve replacement remains to be found regarding longevity, freedom of anticoagulation and availability in each size. Purpose Examination of a new technique for a regenerative, immunocompatible, transcatheter pulmonary valve implant from autologous pericardium was performed in an adult sheep model. Methods For each valve implant a pericardial patch was harvested by left antero-lateral mini-thoracotomy, placed on one of two slightly different shaped moulds either made of acrylic glass (AG) or printed in a 3D Printer (3D) and transferred into a container filled with a biological crosslinking agent at a non-toxic concentration to stabilize the given shape. After a median of 3 days (d) they were unpacked, sewn into a self-expandable nitinol stent with a diameter of 26 or 30mm and implanted via the jugular vein into pulmonary valve position of the same animal using a custom-made delivery system (1). Three groups (Gr) were planned: Gr 1) 4 animals with at least 6 d of crosslinking and AG mould; Gr 2) 5 animals with at least 3 d of crosslinking and AG mould; Gr 3) 6 animals with at least 3 d crosslinking and 3D mould. Follow ups (FU) were performed every 3 months (mo) evaluating valve function by intracardiac echocardiography (ICE) and cardiac MRI for up to 20.5 mo. All experiments were approved and conducted according to German federal law. Results In 11 of 13 animals minimally-invasive implantation was successful. One animal died because of ventricular fibrillation, in the other the implant dislocated into the right ventricle, so it had to be sacrificed. Direct post-implantation valve insufficiency was evaluated in 9 animals using ICE or angiography. In Gr 1 insufficiency was non-existent (n=2), in Gr 2 moderate or severe (n=2) and in Gr 3 non-existent or mild (n=5). Long term function as shown in figure 1 decreased rapidly in Gr 1 and 2 with median MRI regurgitation fractions (RF) in Gr 1 of 31% at 3 mo (n=3), 41% at 6 mo (n=3), 48% at 9 mo (n=2), 47% at 12 mo (n=3) and in Gr 2 of 43% at 3 and 54% at 6 mo (n=1) after implantation. Median RF in Gr 3 was small with 9% at 3 mo (n=4), 8% at 6 mo (n=3), 8% at 9 mo (n=3), 12% at 13 mo (n=3), 8% at 17 mo (n=2) and 20.5 mo (n=2). We never witnessed valve stenosis in any group at any point in time. Conclusion Gr 3 showed promising results regarding long time function of the implant which encourages further research with higher validity. The reason for failing of Gr 1 and 2 remains a topic of discussion. Regardless, valuable experience was gained in crafting and conducting the implantation of this new regenerative heart valve implant. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EXIST research transfer program of the federal ministry of education and research

STERNUM-SPARING LEFT VENTRICULAR ASSIST DEVICE INSERTION REDUCES BLOOD LOSS AND PERIOPERATIVE TRANSFUSIONS: INITIAL CANADIAN EXPERIENCE

<h3>BACKGROUND</h3> In end-stage heart failure, left ventricular assist devices (LVADs) improve survival and quality of life as destination therapy or bridge to transplantation. This sternum-sparing approach avoids the complications of sternotomy and the risk of sternal re-entry for transplantation. There may also be benefits associated with less blood loss and transfusion. Though less-invasive hemisternotomy approaches are well studied, there is a paucity of data in the literature for sternum-sparing BMT. Our center has one of Canada's largest experiences with the BMT approach. Herein, we compared LVAD implantation via BMT with patients who received full median sternotomy or hemisternotomy. <h3>METHODS AND RESULTS</h3> LVAD implantation via bilateral minthoracotomy (image) uses a left anterolateral minithoracotomy for device implantation and right anterior minithoracotomy for aortic anastomosis of the outflow graft. Pericardial tunnelling of the outflow graft retains the pericardium as a barrier between the sternum and heart. A single centre retrospective review was performed at the Foothills Medical Centre (Calgary, Canada) for patients undergoing LVAD insertion from 2012 to 2019. Data was collected from chart review and the Metavision Database. Patients received either BMT (n=11) or sternotomy (full median sternotomy or upper hemisternotomy with left thoracotomy; FS/HS; n=41). Continuous and categorical variables were analyzed by Wilcoxon Rank Sum and Chi-Squared tests respectively. The accompanying table shows patient demographics and perioperative outcomes. Patients receiving BMT were younger and there were no other significant differences in group characteristics related to INTERMACS classification, etiology of heart failure and cardiovascular risk factors. BMT had similar cardiopulmonary bypass times and cross-clamp times to the FS/HS group. There were no differences in stroke or mortality. BMT reduced total intraoperative and CVICU transfusions of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets when compared to the full/hemisternotomy group. Additionally, BMT had reduced chest tube outputs in the first 12 hours after LVAD implantation. <h3>CONCLUSION</h3> Outcomes suggest sternum-sparing LVAD implantation is a safe alternative to sternotomy with less post-operative blood loss and transfusion in the early Postoperative period. Less transfusion is particularly valuable in this patient population to reduce antigen-related sensitization prior to transplantation. Additional study is needed to assess potential benefits of this approach for post-operative mobility and patient-reported quality of life metrics.

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy.

Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization. We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6months following discharge. Mean age of patients was 52.5 ± 9.8years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent. Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

My HeartWare implantation technique: tricks and pitfalls.

The rotary blood pump (the HeartWare® Ventricular Assist Device) from HeartWare® (Medtronic) is an established left ventricular assist device and usually implanted via sternotomy. To reduce the invasiveness of the implant procedure and to optimize the position of the inflow cannula, we propose an alternative implant technique with an extrapericardial placement of the pump via left anterolateral minithoracotomy. However, the minimally invasive approach is not suitable in patients in need of an additional cardiac procedure or with thrombus formation in the left atrial appendix. Preservation of the pericardium may reduce adhesions in future surgery such as heart transplantation, and an 'off pump' thoracotomy approach is feasible in patients without intraventricular thrombus.

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.

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.

Experimental transapical endoscopic ventricular visualization and mitral repair.

An increasing number of experimental beating heart animal studies describe simple transapical mitral valve repairs based on the direct endoscopic visualization of the left ventricle. The aim of our human cadaveric study was to develop a method for more complex transapical endoscopic procedures by on-pump heart operations. After preparation of 20 human fresh cadavers, a standard left anterolateral minithoracotomy was performed in the fifth intercostal space and the pericardium was entered. A rigid 0 degree endoscope and the instruments were introduced through a silicon apical port. To restore the natural form of the left heart, CO2 was insufflated. To test the mitral valve competence, the left ventricle was pressure-injected with saline after each step. After transecting the chords of the A2 segment of the anterior mitral leaflet before the experimental mitral valve repair, the tendinous chord was replaced using an especially designed clip chord. The second part of the experiment consisted of a segmental excision of the P2 segment of the posterior mitral leaflet followed by a standard valvuloplasty and suture annuloplasty. With the help of the described transapical endoscopic mitral valve repair technique, we gained direct visual information of the coaptation line of the mitral leaflets as well as the anatomy and function of the subvalvular apparatus. Using intracardiac imaging, we could perform successful transapical complex mitral repair in each case. The minimally invasive transapical endoscopic method has the potential to offer advantages for on-pump mitral valve repair procedures even in complex mitral valve repair cases.

Minimal-Invasive LVAD Implantation, Is It Safe or Even Better?

Purpose The rotary blood pump (HVAD) from HeartWare is an established left ventricular assist device and usually implanted via sternotomy. To reduce the invasiveness of the implant procedure and to optimize the position of the inflow cannula we propose a different implant technique with an extrapericardial placement of the pump via left anterolateral minithoracotomy. Methods and Materials In a time period of 7 months 28 of 42 patients were implanted with the HVAD using a minithoracotomy for pump placement in combination with an upper hemisternotomy for anastomosis of the outflow graft. In 11 of these patients implant procedure was performed without extracorporeal circulation. The implantation was in 31% a redo-procedures. The 25 male and 3 female patients were in mean 55 years old. Diagnosis was DCM in 15 and ICM in 13 patients. Implants were performed at Intermacs levels 1-4. Results Mean follow up was 107 days. There was 1 death due to right heart failure in this patient cohort. One conversion to full sternotomy was required. Optimal positioning of inflow cannula was confirmed by 3D Echo. One pump thrombosis and two driveline infections were observed. Conclusions Placement of the HVAD via thoracotomy is superior in terms of inflow position. Preservation of pericardium may reduce distention of the right heart. “Off pump” approach is feasible in patients without intraventricular thrombus. Optimal placement of inflow may have positive effect on pump performance and possibly adverse event rates in the follow up.

A Hybrid Approach to Cardiac Resynchronization Therapy

CRT (atrial-synchronized bi-ventricular pacing) has been shown to significantly improve the quality of life and exercise tolerance in patients with moderate-severe heart failure and an interventricular conduction delay (>120 msec) when compared to controls. Traditionally it has been performed by cardiologists in electrophysiology laboratories. In the event that the left ventricular lead cannot be positioned percutaneously the procedure is aborted and the cardiac surgeon consulted. The subsequent intervention by the surgeon, typically on another day, requires reexploration of the pocket, a thoracotomy, which results in an increase in length of stay (LOS), and an increase in infection risk. The objective of this study was to demonstrate that CRT could routinely be performed in a surgical operating room (OR) as a single rather than a staged procedure. Between 1/1/06 and 7/1/06 18 patients (17 male and 1 female) with an average age of 56 years (range 36-79) underwent CRT. Transthoracic echo (TTE) revealed that all had left ventricular ejection fractions (LVEF) <30% (range 8%-28%). Five of the 18 had moderate-severe mitral regurgitation (MR). The etiology of the cardiomyopathies was ischemia in 4 and non-ischemia in 14. All had QRS intervals >120 msec (range 120-200 msec) and all were maintained preoperatively on their conventional therapy for heart failure (B-blockers, ± diuretic, ± ACE-I or ARB) and all were either New York Heart Association (NYHA) functional class III or IV. Every case was performed under general anesthesia with an arterial line and Foley catheter in the semi right lateral decubitous position. Nine of the 18 patients underwent a left anterolateral mini-thoracotomy for epicardial left ventricular (LV) lead placement. All hardware included defibrillation technology (ICD). All 18 patients left the OR with successful bi-ventricular pacing in an average time of 170 minutes (range 140-200 min). The average epicardial lead pacing threshold was 0.9v (range 0.4-1.5v) while the average endocardial (transvenous) threshold was 0.4v (range 0.2-0.7v) at a pulse width of 0.5 msec. TTE at 1 month demonstrated an improvement in LVEF in 14/18 patients with an average increase of 5% (range 2%-9%). Four of the 5 patients with moderate-severe MR were reduced to mild. The average length of stay (LOS) following the procedure, in those patients who did not undergo a thoracotomy, was 4 days (range 3-6 days) while it was 7 days (range 6-10 days) in those who underwent a thoracotomy. These data clearly indicate that CRT can be successfully performed as a single-staged procedure in a cardiac OR. Although transvenous LV lead placement avoids a thoracotomy, the epicardial LV lead thresholds, in this series, are competitive with the transvenous results. We propose that in the spirit of cost containment, fee bundling, decreasing reimbursement, pay-for-performance, and infection control, these complex interventions should be performed in multipurpose interdisciplinary hybrid cardiac OR's, now available in most major medical centers, with designated time limitations and role assignments.

Transcatheter aortic valve implantation (TAVI): state of the art techniques and future perspectives

Transcatheter aortic valve therapies are the newest established techniques for the treatment of high risk patients affected by severe symptomatic aortic valve stenosis. The transapical approach requires a left anterolateral mini-thoracotomy, whereas the transfemoral method requires an adequate peripheral vascular access and can be performed fully percutaneously. Alternatively, the trans-subclavian access has been recently proposed as a third promising approach. Depending on the technique, the fine stent-valve positioning can be performed with or without contrast injections. The transapical echo-guided stent-valve implantation without angiography (the Lausanne technique) relies entirely on transoesophageal echocardiogramme imaging for the fine stent-valve positioning and it has been proved that this technique prevents the onset of postoperative contrast-related acute kidney failure. Recent published reports have shown good hospital outcomes and short-term results after transcatheter aortic valve implantation, but there are no proven advantages in using the transfemoral or the transapical technique. In particular, the transapical series have a higher mean logistic Euroscore of 27-35%, a procedural success rate above 95% and a mean 30-day mortality between 7.5 and 17.5%, whereas the transfemoral results show a lower logistic Euroscore of 23-25.5%, a procedural success rate above 90% and a 30-day mortality of 7-10.8%. Nevertheless, further clinical trials and long-term results are mandatory to confirm this positive trend. Future perspectives in transcatheter aortic valve therapies would be the development of intravascular devices for the ablation of the diseased valve leaflets and the launch of new stent-valves with improved haemodynamic, different sizes and smaller delivery systems.

Right or left anterolateral minithoracotomy for repair of congenital ventricular septal defects in adult patients

For most patients who present with ventricular septal defects (VSDs) in adulthood, the major concern is not the mortality or morbidity associated with repair surgery, but rather cosmetic problems arising from surgical scarring as a result of median sternotomy. From March 2005 to August 2008, nine patients (M:F=1:8) underwent repair of congenital VSD using right (n=7) or left (n=2) anterolateral minithoracotomy. We compared the perioperative data of these patients with that of the patients (n=8) who underwent VSD repair using median sternotomy during the same period. VSDs were of the perimembranous (n=6), subarterial (n=1), muscular inlet (n=1), and muscular outlet (n=1) type in minithoracotomy group. There was no in-hospital mortality in both groups. Mean cardiopulmonary bypass (CPB) time in minithoracotomy group was longer than that of sternotomy group (98.0+/-23.7 min vs. 68.5+/-13.3 min, P=0.011), but aorta cross-clamping (ACC) time was not different (45.9+/-20.0 min in minithoracotomy group vs. 40.5+/-12.1 min in sternotomy group) (P=0.481). There were no postoperative complications related to surgery or peripheral cannulation. The mean hospital stay was 3.6 days in minithoracotomy group and 6.1 days in sternotomy group, respectively (P=0.004). Minimally invasive cardiac surgery using minithoracotomy with peripheral cannulation can be safely applied to adult VSD patients irrespective of VSD type.

EComment: Re: Right or left anterolateral minithoracotomy for repair of congenital ventricular septal defects in adult patients

eComment: Re: Right or left anterolateral minithoracotomy for repair of congenital ventricular septal defects in adult patients

INVITED COMMENTARY

This article demonstrates the effectiveness of a new tool for epicardial lead placement that has been developed by Medtronic. It represents a modification of a previously marketed device used for implantation of screw-in epicardial leads. The malleable shaft allows perpendicular positioning of the lead on the posterolateral surface of the left ventricle when approached through a left anterolateral minithoracotomy. The paper describes successful positioning of the lead in 7 patients with congestive heart failure. Advantages of the approach that allow placement of the lead through a small incision, with minimal manipulation of the heart, are obvious. One important aspect of the technique is not clearly discussed in this report. How was optimal positioning of the posterolateral lead determined? Were hemodynamic measurements made, and if so, how were they used to guide lead placement? I believe that this new device will prove to be very useful in patients with heart failure who require a minimally invasive approach to biventricular pacing.