Minimal Invasive Aortic Valve Research Articles

New tools in minimal invasive aortic valve surgery: case report

Video 1 This is a standard case of aortic valve regurgitation of a 65 years old female, with known disease since 2008 and symptomatic in functional class II. At the echo valved looked bicuspid. The operations scheduled was aortic valve replacement with a tissue valve (actually was a CE num 19) through a J sternotomy. An innovative device composed by two staples, called RAM® and the other SEW-EASY®, was intended to use for suturing the prosthesis. Also, the use of another well-known device, aimed to tied suture, called COR-KNOT® was established. After central cannulation and selective delivery of cardioplegia, aortic cusps are resected. With the RAM® device the two ends of the tread with the Teflon pledget are passed equidistant in the aortic annulus, after previous loading of the stitch in to the device. Then, with the called SEW-EASY® device, stitches are also symmetrically passed thought the sewing ring of the prosthesis. After the prosthesis is parachuted, the COR-KNOT® device was used to finally tied the stitches. The intraoperative echo showed well positioned prosthesis, without paravalvular leak.

Bundle Branch Re-Entrant Ventricular Tachycardia after Minimal Invasive Cardiac Surgery

Background: Bundle branch re-entrant ventricular tachycardia (BBRVT) is a monomorphic ventricular arrhythmia with wide QRS complexes caused by re-entrant tachycardia between both bundle branches. BBRVT can occur in a variety of cardiac pathologies with His–Purkinje system (HPS) conduction abnormalities such as dilated cardiomyopathy, coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease and even after aortic valve surgery. Case report: A 62-year-old male patient with an ischemic cardiomyopathy and implantable cardioverter defibrillator (ICD) underwent minimal invasive aortic valve replacement (Yil-AVR) and coronary artery bypass graft (CABG). He was remitted a week later because of relapsing sustained ventricular tachycardia (VT). Electrocardiogram showed a wide QRS tachycardia, which was remarkably similar to the patient’s sinus rhythm. Analysis of ICD revealed the presence of BBRVT. Catheter ablation of the right bundle branch (RBB) was performed. He is currently in clinical follow-up and no reoccurrence of VT has been recorded so far. Conclusion: Patients with known cardiomyopathy can develop BBRVT early after cardiac surgery. To our knowledge, this is the first time that BBRVT occurred after Yil-AVR.

Minimal Invasive Aortic Valve Replacement by Upper Ministernotomy Approach in Comparison to The Conventional Full Median Sternotomy Approach

Minimal Invasive Aortic Valve Replacement by Upper Ministernotomy Approach in Comparison to The Conventional Full Median Sternotomy Approach

Minimal Invasive Aortic Valve Replacement Through Right Mini_Thoracotomy Versus Conventional Approach In The Egypt

Background: Full median sternotomy was established a long time ago as the standard approach for all varieties of heart surgery. Although that, it may cause significant surgical trauma and morbidity, so minimally invasive cardiac surgery for aortic valve replacement via partial sternotomy, para-sternal approach and anterior mini-thoracotomy is used trying to improve the outcome . Objective: to check the outcome of minimally invasive aortic valve surgery through a right mini-thoracotomy, and its rule in minimizing the surgical access, achieving better wound appearance, decreasing post-operative discomfort and better postoperative recovery with the same safety and results like conventional surgery . Methods: our study was performed in the Armed Forces Hospitals El Maddi& El Galaa and kobry elkobba, Egypt. Between January 2015 to March 2017, sixty patients were diagnosed with AVD requiring aortic valve surgery were randomly selected, of them Thirty patients had aortic valve surgery through full median sternotomy with aorto-right atrial cannulation and the other thirty patients had right mini-thoracotomy with femoral cannulation . Results# Minimally invasive aortic valve replacement (MIAVR) was associated with reduced morbidity and mortality, where there was a safer approach in case of re-operation, better cosmetic outcome, less bleeding post-operative, lower number of blood products usage, less intensive care unit and hospital stays, decreased time until return to full activity and avoiding the incidence of sternal wound infection. That good results were also achievable in high-risk patients . Conclusion: Minimal Invasive Aortic Valve Replacement Through Right Mini-thoracotomy is an acceptable alternative to Full median sternotomy, has reduced morbidity and potential mortality and good clinical outcome, with two concerns which are the operative cost and the relatively long bypass and cross clamp time which are related to the learning curve of the surgeons

Minimal invasive aortic valve replacement: associations of radiological assessments with procedure complexity

ObjectivesLimited aortic annulus exposure during minimal invasive aortic valve replacement (mini-AVR) proves to be challenging and contributes to procedure complexity, resulting in longer procedure times. New innovations like sutureless valves have been introduced to reduce procedure complexity. Additionally, preoperative imaging could also contribute to reducing procedure times. Therefore, we hypothesize that Computed Tomography (CT)-image based measurements are associated with mini-AVR complexity.MethodsOne hundred patients who underwent a mini-sternotomy and had a preoperative CT scan were included. With a CT-based mini-AVR planning tool, we measured access distance, access angle, annulus dimensions, and calcium volume. The associations of these measurements with cardiopulmonary bypass (CPB) time and aortic cross-clamp (AoX) time were assessed using univariable and multivariable regression models. In the multivariable models, these measurements were adjusted for age and suture technique.ResultsIn the univariable regression models, calcium volume and annulus dimensions were associated with longer CPB and AoX time. After adjusting for age and suture technique, increasing calcium volume was still associated with longer CPB (adjusted β-coefficient 0.002, 95%-CI (0.005, 0.019), p-value = 0.002) and AoX time (adjusted β-coefficient 0.010, 95%-CI (0.004, 0.016), p-value = 0.002). However, after adjusting for these confounders, the association between annulus dimensions and procedure times lost statistical significance.ConclusionIncrease in calcium volume are associated with longer CPB and AoX times, with age and sutureless valve implantation as independent confounders. In contrast to previous studies, access angle was not associated with procedure complexity.

Carbon dioxide de-airing in minimal invasive cardiac surgery, a new effective device

BackgroundArterial air embolism during open heart surgery may cause postoperative complications including cerebral injury, myocardial dysfunction, and dysrhythmias. Despite standard de-airing techniques during surgery large amounts of arterial air emboli may still occur, especially during weaning from cardiopulmonary bypass. To prevent this insufflation of carbon dioxide in the wound cavity has been used since the 1950s. The aim of this study was to assess a new mini-diffuser for efficient carbon dioxide de-airing of a minimal invasive cardiothoracic wound cavity model. Up until now no device has been evaluated for this purpose.MethodsA new insufflation device, a mini-diffuser, was tested. A thin plastic tube was used as control. The end of the mini-diffuser or the control, respectively, was positioned in a minimal invasive thoracic wound model. Remaining air content was measured during steady state and during intermittent suction with a rough suction device at different carbon dioxide flow rates. Measurements were also carried out in the open surgical wound during minimal invasive aortic surgery in six patients.ResultsThe air content was below 1% 4 cm below the surface of the open wound model during continuous carbon dioxide inflow of 2–10 L/min with the mini diffuser. In comparison, carbon dioxide insufflation via the open-ended tube resulted in a mean air content between 10 and 75%. The mean air content of the wound model remained below 1% at a carbon dioxide flow rate of 3–5 L/min during intermittent application of a suction device with a suction rate of 15 L/min. In 6 patients undergoing minimal invasive aortic valve replacement air content in the open surgical wound remained below 1% at a continuous carbon dioxide flow rate of 5 and 8 L/min via the mini-diffuser, respectively.ConclusionsThe mini diffuser was effective for carbon dioxide de-airing, i.e. < 1% remaining air, of a minimal invasive cardiothoracic wound cavity model with and without intermittent rough suction as well as in patients undergoing minimal invasive aortic valve surgery.

Long-term outcomes following minimal invasive versus conventional aortic valve replacement: a propensity match analysis.

Minimal invasive aortic valve replacement has become a routine procedure. In this study, we compared the outcomes between conventional and minimal invasive aortic valve replacement via the partial upper sternotomy that were performed in our Institution. The 5 year survival and postoperative outcomes of 34 patients that underwent isolated MIAVR between the years 2010-2013 were compared with the outcomes of 34 randomly selected patients that underwent conventional AVR, after propensity match analysis. There was no difference between the two groups concerning the early and late postoperative outcomes. MIAVR patients had a longer mean cross-clamp time (p = 0.002) and longer cardiopulmonary bypass time (p = 0.0005) compared to the AVR patients. 5 year mortality and survival were 4.17 % vs 16.67 % (p = 0.20) and 95.8 % vs 83.3 % (p = 0.37) in the MIAVR and AVR groups respectively. This study showed a comparable 5 year survival and postoperative outcomes between the MIAVR and AVR groups. In our opinion, the minimal access aortic valve replacement can be performed safely with excellent long-term results in selected patients (Tab. 4, Fig. 1, Ref. 35).

Minimal Invasive and Sutureless Technology: Are These Advantages for Patients Undergoing Aortic Valve Replacement?

Objectives: Minimal invasive aortic valve replacement (AVR) could cause less morbidity than conventional surgery, but up to now strong clinical advantages are not yet demonstrated. The use of sutureless aortic valve prostheses in addiction could reduce the surgical time. However, whether shorter surgical time results in improved patient outcome remains to be determined.

Intuity Elite Valve Implantation Technique

With the advent of transcatheter aortic valve replacement (AVR) and expanding treatment populations, there has been significant impetus to innovate the standard surgical AVR, particularly through minimally invasive approaches. Minimal invasive surgical aortic valve replacement (MIS AVR) is associated with improved cosmesis, decreased bleeding, reduced ventilation times, shorter intensive care unit and hospital lengths of stay, and improved early and long-term survival when compared with conventional full sternotomy AVR. However, MIS AVR is also associated with prolonged aortic cross-clamp and cardiopulmonary bypass times, reflecting the increased technical complexity of these operations. Using knowledge gained from the transcatheter experience, several rapid deployment and sutureless aortic valves have been developed to facilitate minimally invasive approaches and reduce operative times. These devices have been employed for several years in Europe and have recently achieved regulatory approval in the United States. Rapid deployment and sutureless valves have been associated with significantly reduced cardiopulmonary bypass times, excellent hemodynamics, and acceptable rates of pacemaker implantation and paravalvular leak. Herein, we discuss the technical details for MIS AVR using the Intuity Elite rapid deployment valve system (Edwards Lifesciences, Irvine, CA).

Lessons from modular approach to training for minimally invasive aortic valve replacement : implications for training and outcome

Minimally-invasive Aortic Valve Replacement (mini-AVR) is being increasingly adopted in clinical practice. Training can be a challenge due to the inherent difficulties of limited surgical exposure. We analysed individual trainee experience in our institutional undergoing mini-AVR training within a series of our cases where all AVRs are routinely undertaken by this approach.

Minimal invasive aortic valve replacement surgery is associated with improved survival: a propensity-matched comparison†

To compare early and long-term outcomes of minimally invasive surgery (MIS) versus full sternotomy (FS) isolated aortic valve replacement (AVR). We retrospectively analysed all patients who underwent isolated bioprosthetic AVR between 2003 and March 2012 at our institution. Matching was performed based on a propensity score, which was obtained using the output of a logistic regression on relevant preoperative risk factors. Mean follow-up was 3.1±2.7 years (range 0-9.0 years) and was 99.8% complete. A total of 2051 patients (FS, 1572; MIS, 479) underwent isolated bioprosthetic AVR during the study period. MIS patients were significantly younger (67.8±11.2 vs 70.4±9.4 years) and had a lower logistic EuroSCORE (6.6±6.4 vs 11.2±13.4%, both P<0.001). Propensity matching resulted in 477 matched patients from each group, with no significant differences in any of the preoperative variables. Aortic cross-clamp times were significantly longer in MIS patients (59.4±16.0 vs 56.9±14.6 min, P=0.008). Nonetheless, MIS AVR was associated with a significantly lower incidence of intra-aortic balloon pump usage (0.4 vs 2.1%, P=0.042) and in-hospital mortality (0.4 vs 2.3%, P=0.013), while FS patients had a lower rate of re-exploration for bleeding (1.5 vs 4.2%, P=0.019). Five- and 8-year survival post-AVR was significantly higher in MIS patients (89.3±2.4% and 77.7±4.7% vs 81.8±2.2% and 72.8±3.1%, respectively, P=0.034). Cox regression analysis revealed MIS (hazard ratio: 0.47, 95% confidence interval: 0.26-0.87) as an independent predictor of long-term survival. MIS AVR is associated with very good early and long-term survival, despite longer myocardial ischaemic times. MIS AVR can be performed safely with results that are at least equivalent to those achieved through an FS.

TCT-739 TAVI Karlsruhe (TAVIK) - a comparison of minimal invasive and surgical aortic valve replacement in patients with severe symptomatic aortic stenosis and intermediate risk for conventional surgery

SAVR is the standard procedure for symptomatic aortic stenosis while TAVI is the method of choice in patients at high risk. It is gaining increasing importance in intermediate risk patients but to date there are limited data to assess benefits and risks. Analyses were based on the TAVIK registry of

Pre-Operative 3D CT Imaging for Virtual Planning of Minimally Invasive Aortic Valve Surgery

MANY DIFFERENT APPROACHES ARE AVAILABLE FOR PERFORMING MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT (AVR). The most commonly used incision is the upper hemi-sternotomy, which extends from the sternal notch to the right fourth intercostal space (ICS). Variations in the location of the valve within the

Occurrence of acute renal failure in elderly patients undergoing TAVI respectively minimal invasive surgical aortic valve replacement (MIS): Which procedure is to prefer?

Objective: Acute Kidney injury (AKI) represents a major complication following surgical aortic valve replacement (AVR) in elderly patients. Nevertheless, there is no evidence if the incidence of AKI is higher after minimal invasive valve replacement with extracorporeal circulation (MIS-AVR) or transapical valve implementation (TAVI). The aim of this study was to determine the ideal operative strategy for the treatment of symptomatic aortic stenosis in patients ≥75 years regarding the postoperative renal function.

EComment. Learning curves in coronary revascularization

We would like to comment on the interesting article by Sepehripour and Athanasiou [1], and the related comment by Bougioukakis et al. [2]. We totally agree that the matter of learning curve is one of utmost importance for every medical and surgical diagnostic or therapeutic procedure. This applies to both the individual physician as well as to the surrounding team, as all of them require a procedure-related time and cases period in order to get acquainted with the method and offer the best possible results. However, we would like to have, if possible, the authors' and commentators' opinion on the off-pump procedure itself. In addition to the relatively long learning curve, it is believed that many of the alleged advantages of beating heart over on-pump surgery, such as benefits regarding the postoperative neurocognitive function, do not really exist. This is based on more recent data [3], unlike with what was believed in the past [4]. Do the authors believe that the junior surgical staff of a cardiothoracic department must be directed towards the training of off-pump heart surgery rather than other more promising procedures, such as minimal invasive aortic and mitral valve procedures? Conflict of interest: none declared

P-20 Hyponatraemia after “Bretschneider” cardioplegia during minimal invasive aortic valve replacement

P-20 Hyponatraemia after “Bretschneider” cardioplegia during minimal invasive aortic valve replacement

Sutureless Aortic Valve Replacement via Partial Sternotomy

: For elderly patients with symptomatic aortic valve stenosis, aortic valve replacement with tissue valves is still the treatment of choice. Stentless valves were introduced to clinical practice for better hemodynamic features as compared with stented tissue valves. However, the implantation is more complex and time demanding, especially in minimal invasive aortic valve replacement. We present our clinical data on 22 patients having received a sutureless ATS 3f Enable aortic bioprosthesis via partial upper sternotomy. : The procedure was performed using CPB with cardioplegic arrest. After resection of the stenotic aortic valve and debridement of the annulus, the valve was inserted and released. Mean age was 79 years, and mean logistic Euroscore was 13. Subvalvular myectomy was performed in two patients. Prosthetic valve sizes were 19 mm (n = 1), 21 mm (n = 7), 23 mm (n = 6), 25 mm (n = 6), and 27 mm (n = 2). : Implantation of the valve required 10 ± 6 minutes. Cardiopulmonary bypass and aortic crossclamp time were 87 ± 16 and 55 ± 11 minutes, respectively. Early mortality (<90 days) was 9% (2 patients). No paravalvular leakage was detected intraoperatively or in follow-up echocardiography. The mean transvalvular gradients were 9 ± 6 mm Hg at discharge and 8 ± 2 mm Hg at 1-year follow-up. : Sutureless valve implantation via partial sternotomy is feasible and safe with the ATS 3f Enable bioprosthesis. Reduction of cardiopulmonary bypass and aortic crossclamp time seems possible with increasing experience. Hemodynamic data are very promising with low gradients at discharge and after 12 month. Sutureless valve implantation via minimal invasive access may be an alternative treatment option for elderly patients with high comorbidity.

Successful Transapical Aortic Valve Replacement in a Patient With a Previous Mechanical Mitral Valve Replacement

In this case we illustrate our experience with transapical minimal invasive aortic valve replacement in a patient who previously underwent mitral valve replacement. The implantation did not interfere with the existing prosthesis and could even be used as a further landmark, helping height positioning of the aortic valve.

Pulmonary trunk perforation during transapical minimal invasive aortic valve replacement

In this case report we illustrate our experience with a perforation of the pulmonary trunk during a transapical aortic valve implantation in a single case. The patient suffered from an aortic valve stenosis and was accepted for a minimally invasive procedure because of multiple comorbidities. After unproblematic transapical placement of the aortic valve, a venous bleeding from the anterolateral wound was observed. Median sternotomy showed a bleeding out of the pulmonary trunk that could be stopped with purse-string sutures. The further course of the patient was uneventful.

Moguntia cardioplegia in minimal invasive aortic valve replacement; an alternative to Bretschneider cardioplegia?

Introduction: We designed a low-cost cristalloid cardioplegic (CP) solution (Moguntia CP), a modification of Bretschneider CP. In patients with severe cardiac hypertrophy due to aortic stenosis, intra-operative cardioprotection by CP solutions is challenging. We therefore evaluated the effect of Moguntia CP in this high risk patient group that underwent a Minimal Invasive Aortic Valve Replacement (MI-AVR).