Minimally Invasive Cardiac Surgery Research Articles

Hundred plus Minimally Access Cardiac Surgery: Our Experience

Background: Minimally invasive procedures lead to less scarring resulting in better cosmetic outcomes. This has resulted in increased patient interest in such procedures and this has motivated surgeons to pursue newer and improved techniques for Minimally invasive cardiac surgery (MICS). Obviously, with the advent of MICS the techniques to achieve it also needed to be changed and upgraded which includes access for cannulation for cardiopulmonary bypass (CPB). Right internal jugular vein percutaneous cannulation, together with the direct surgical cannulation of femoral vessels with minithoracotomy/ministernotomy proves to be a safe and effective tool in patients with body weight of above 20 kg for minimally access cardiac surgery. We use this technique for Atrial septal defect (ASD) closure, aortic valve replacement (AVR), redo Tricuspid valve replacement (TVR) and mitral valve replacement (MVR). Here, we describe our experience with minimally invasive approach using total peripheral cannulation and an anterior mini-thoracotomy (6 cm or less) incision for ASD closure, AVR, TVR and MVR. Methods: The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive ASD closure, AVR, TVR and MVR with total peripheral cannulation were collected and analyzed. Results: Between May 2014 to May 2019 we performed minimally invasive closure of atrial septal defects, AVR, TVR and MVR with total peripheral cannulation in 103 patients. There were 64 females and 39 males Mean age was 25 years (range 8 - 58 years), Spectrum of procedures include ASD closure in 81 patients (78.6%), AVR via minithoracotomy in 13 patients (12.6%) and AVR via ministernotomy in 3 patients (2.9%), redo TVR in 5 (4.8%), MVR in 1 patient (0.97%). Average cardiopulmonary bypass (CPB) time was 46 minutes (range 22 - 78 min) and average aortic cross-clamp time (AoX) 26 min (range 12 - 45 min) in ASD closure group. In AVR group average CPB time was 91 min (range 72 - 120 min) and AoX time 76.5 min (range 65 - 109 min). In TVR group average CPB time 54 min (range 45 - 67 min) on beating heart. Only one MVR done in this period and CPB time was 82 min and AoX time was 65 min. The mean length of stay in intensive care unit was 1.8 days in ASD closure, 2 days in AVR group when in TVR group 3.5 days, and hospital stay was 3 days in ASD closure group, 4 days in AVR group and 7 days in TVR group. The only one patient who underwent MVR died in 12th post operative day from sepsis. There was one late mortality in AVR group after reoperation for prosthetic valve endocarditis at 3 months from first operation. Conclusion: ASD closure, AVR, TVR and MVR with mini invasive approach is safe with very few manageable preoperative complications and good patient satisfaction.

Perfusion Strategy for Minimally Invasive Cardiac Surgery

Minimally invasive cardiac surgery (MICS) has a number of proven advantages compared to median sternotomy. Safe cannulation and perfusion are some of the main components of the success of MICS.
 The aim. To present our perfusion strategy and describe the methods of cannulation, technical features, contraindications and potential complications.
 Materials and methods. We examined the results of 1088 adult patients who underwent primary cardiac surgery in our hospital (coronary artery bypass grafting, valve surgery, aortic surgery, left ventricle repair, congenital cardiac surgery and combined procedures) from July 2017 to May 2021. Of these, 851 patients were qualified for MICS. To select a safe cannulation strategy, we performed contrast enhanced computed tomography (CT) of the aorta and main branches for all the patients, also we calculated the body surface area according to the DuBois and DuBois formula.
 Results. We performed 838 minimally invasive on-pump procedures, which is 98.5% of all patients qualified for MICS. According to the results of the preoperative CT scan, 13 (1.5%) patients were not operated with the minimally invasive approach due to the hazards related to the provision of cardiopulmonary bypass. Peripheral cannulation was performed in 754 (90%) patients and an alternative cannulation site was selected in 62 (8.2%) patients based on preoperative CT data. There were 10 (1.32%) patients who developed major complications (stroke, acute aortic dissection, acute renal failure requiring hemodialysis) after peripheral cannulation.
 Conclusions. Preoperative CT scan is mandatory for planning a perfusion strategy in minimally invasive cardiac surgery. The required surgical techniques should include cannulation of the right and left femoral and right axillary arteries.

Comparison of Short-Term Results between Minimally Invasive Cardiac Surgery and Conventional Median Sternotomy for Atrial Septal Defect Closure

Background: Median sternotomy (MS) is the standard approach for atrial septal defect (ASD) closure. Recently, minimally invasive cardiac surgery (MICS) for ASD closure via right mini-thoracotomy has been proposed as a promising alternative approach. Objective: To compare short-term results of standard median sternotomy with minimally invasive cardiac surgery for ASD closure in Ramathibodi Hospital. Materials and Methods: The authors retrospectively analyzed 59 patients who underwent surgical ASD closure between January 2014 and July 2020. There were 32 patients in MICS group and 27 patients in MS group. Patient demographic datas, intraoperative parameters and postoperative results were collected and compared between the two groups. Results: There were no statistically significant difference in age, gender, body mass index, mean pulmonary artery pressure and left ventricular ejection fraction between the two groups. Intraoperative parameters were not difference in ASD size, concomitant procedures and aortic cross-clamp time. Complete atrial septal defect closure were achieved in all patients of both groups without residual defect. Median cardiopulmonary bypass time was significantly longer in MICS group (91 (77, 140) min vs. 76 (51, 98) min p=0.006). The success rate of MICS approach was 96.9% (31 of 32 patients) and conversion rate was 3.1% (1 of 32 patients). Postoperative median drainage volume and incidence of patients required PRC transfusion were significantly lower in MICS group (270 (145, 480) ml vs. 460 (300, 660) ml p=0.002) and (43% vs. 85% p=0.001) respectively. Postoperative ventilation time, pain score, analgesic drug usage, neurological complications, renal complications, wound infection, ICU stay and hospital stay were similar. Conclusion: MICS for ASD closure is a reliable alternative approach that has lower post-operative drainage volume and incidence of PRC transfusion when compared to standard median sternotomy. However, MICS has longer cardiopulmonary bypass time but no difference in post-operative complications and hospital stay. Keywords: Cardiac surgical procedures; Atrial septal defect; Minimally invasive cardiac surgery; Median sternotomy; Comparison; Short-term results; Minimally invasive ASD closure

Pass On What You Have Learned: A Structured Mentor-Mentee Concept for the Implementation of a Minimally Invasive Mitral Valve Surgery Program

Introduction: Starting a minimally invasive cardiac surgery (MICS) for mitral valve repair (MVR) program is challenging as it requires a new learning curve, but compromising surgical results at the same time is not acceptable. Here, we describe our surgical educational experience of starting a new MICS program at a university heart center in Germany. Methods: A dedicated team for the new MICS program including 2 cardiac surgeons, 1 cardiac anesthetist, 1 perfusionist, and 1 scrub nurse was chosen. The use of long shafted instruments was trained in a low-cost self-assembled MICS simulator, and the EACTS endoscopic dry lab course was visited. Thereafter, 1 MICS center was visited for direct observation and peer-to-peer education for 6 weeks. The mentor observed the first 10 cases performed by the mentee. The surgical mitral valve expertise of 1 single cardiac surgeon was retrospectively analyzed between April 2016 and April 2021. Results: Before the implementation of the MICS-MVR program, 18 mitral valve operations have been performed through sternotomy between April 2016 and October 2018 including 12 replacements and 6 ring annuloplasties. After starting the MICS-MVR program, 73 mitral operations have been performed by the same surgeon of which 53 video-assisted through minithoracotomy (72.6%). 83.1% of the MICS procedures included complex repair (n = 38) and ring annuloplasty (n = 6). Open heart MV surgery was necessary in 20 patients due to concomitant procedures (n = 8), redo procedures (n = 2), severe endocarditis (n = 4), or contraindication for MICS such as PAD (n = 6). There have been no deaths, 1 stroke, and 1 cardiac vascular (RCX) complication. Two patients required conversion to sternotomy and one pericardiocentesis in the long term. Conclusion: Typically, excellent exposure and high repair rates of the MV has led us offer MICS approach to a majority of patients with isolated MV disease. Careful planning and a strict mentor-mentee concept facilitated a safe startup of an MICS program in a busy university heart center.

Abstract 10487: Right Thoracotomy versus Conventional Median Sternotomy in Redo Cardiac Surgery: A 10-Year Single-Centre Experience

Introduction: Minimally invasive cardiac surgery (MICS) has been gaining popularity over conventional sternotomy due to reduced invasiveness. However, in redo cardiac surgery when the risks are higher due to adhesions, few studies compare long-term outcomes. Objective: We aim to compare the perioperative and long-term mortality and stroke/TIA rate in patients undergoing median sternotomy and right thoracotomy for redo cardiac surgery. Secondary outcomes were post-operative and total hospital stay, blood products used, return to theatre and new renal replacement therapy (RRT). Methods: We retrospectively analysed a cohort of 127 sternotomy patients and 29 right thoracotomy patients for redo cardiac surgery between 2010-2020. All patients underwent valve repair or replacement. Patients requiring concomitant cardiac procedures were included. Results: In-hospital and long-term follow-up were 100% and 98.1% complete and a maximum of 10.4 years. There were 52 deaths (33.3%) within the follow-up period. Perioperative mortality was 16.5% in sternotomy versus 3.45% in MICS, although this difference was insignificant after adjustment for logistic EuroSCORE (HR 0.38, [0.05-2.79]). In multivariate analysis, long-term mortality was significantly lower in MICS (HR 0.30 [0.10-0.85]). Adjusted Kaplan-Meier curves revealed lower long-term mortality in the MICS group (p<0.0001). Differences in stroke/TIA rates were insignificant (odds ratio 3.23 [0.85-12.8]). There were significantly less RBC (p=0.0001) and total blood products (p=0.0032) used in the MICS group. All 12 patients who returned to theatre for bleeding complications were in the sternotomy group. Although mean post-operative and total hospital stay and new RRT were lower in the MICS group, these differences were insignificant. Conclusion: MICS for redo cardiac surgery is a safe and effective alternative to median sternotomy without compromising both short-term and long-term clinical outcomes.

Impact of Sarcopenia on Outcomes of Minimally Invasive Cardiac Surgery

Sarcopenia is an objective marker of poor outcome following cardiac surgery through median sternotomy. However, the clinical impact of sarcopenia after minimally invasive cardiac surgery (MICS) has not been well established. This study aimed to analyze the influence of sarcopenia on the early and late outcomes following MICS. We retrospectively examined 1248 patients who underwent MICS via right mini-thoracotomy or upper sternotomy between February 2009 and April 2020. Patients older than 65 years who underwent preoperative computed tomography were enrolled. Sarcopenia was defined as the lowest sex-specific quartile of the body surface area adjusted psoas muscle area. The early operative and late survival outcomes were compared, and the predictor of late composite outcome was analyzed using Cox proportional regression model. Early and late composite outcomes in both groups were also compared. A total of 367 patients were classified into the sarcopenia (n=92) or non-sarcopenia (n=275) group. Patients in the sarcopenia group were older, and had lower preoperative hemoglobin and albumin levels. They had higher estimated surgical mortality, but similar early mortality and major morbidity. The survival and late composite outcome were comparable between the two groups. Sarcopenia was neither an independent predictor of late death nor a composite outcome in the multivariable model. After MICS, patients with sarcopenia displayed comparable perioperative outcomes and survival. The clinical impact of sarcopenia on postoperative outcomes might be alleviated by MICS and early recovery protocol after MICS. MICS could be a reasonable approach for elderly patients with sarcopenia.

Factores asociados al edema pulmonar unilateral después de la cirugía mínimamente invasiva de la válvula mitral

Background and objectivesIn recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors. Material and methodsObservational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017. ResultsA total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3±8.0 vs. 1.84±2.23 days) and longer total hospitalization length-of-stay (15.5±34.7 vs. 10.6±7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24h. ConclusionsThe incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.

Comparison of the safety and efficacy between minimally invasive cardiac surgery and median sternotomy in a low-risk mixed Asian population in Singapore.

Minimally invasive cardiac surgery (MICS) has attracted increasing attention, with institutions increasingly adopting this approach over conventional median sternotomy (MS). This study aimed to describe the outcomes of minimally invasive cardiac surgery in our institution as the only centre with an established MICS programme in Singapore. Patients who had undergone cardiac procedures such as heart valve replacement or repair, coronary artery bypass grafting or atrial septal defect repair were included in the study. We analysed 4063 patients who had undergone MS and 390 patients who had undergone MICS between January 2009 and February 2020. Over the years, the number of MICS procedures performed increased, along with an increase in MICS operations with two or more concomitant cardiac procedures and a decrease in postoperative length of stay. Compared with patients who underwent MS, those who underwent MICS had shorter length of postoperative hospital stay (P < 0.001). On multivariate analysis, patients who underwent MICS had lower rates of atrial fibrillation (P = 0.021), reoperation (P = 0.028) and prolonged ventilation (P < 0.001). However, the rates of other postoperative complications were comparable between patients who underwent MICS and those who underwent MS. In our institution, MICS is a safe, reproducible and efficacious technique that yields superior outcomes compared with conventional MS procedures, in some aspects. The results of this study provide further evidence and support towards adopting the minimally invasive approach to cardiac surgery in a carefully selected group of cardiac patients in Singapore.

Conventional sternotomy versus right mini-thoracotomy versus robotic approach for mitral valve replacement/repair: insights from a network meta-analysis.

Minimally invasive cardiac surgery (MICS) through right mini-thoracotomy as well as robotic surgery has emerged for the last decade for mitral valve surgery. However, their risks and benefits are not fully understood yet. Thus, we conducted a network meta-analysis comparing the early- and long-term outcomes of mitral valve surgery via the conventional sternotomy, MICS, and robotic approaches. MEDLINE and EMBASE were searched through November 2020 to identify randomized controlled trials (RCTs) and propensity-score matched (PSM) trials that investigated early- and long-term outcomes after mitral surgery via the conventional sternotomy, MICS, and robotic approaches. A subanalysis focusing on only subjects who initially underwent mitral valve repair was also conducted. Our systematic literature search identified two RCTs and 19 PSM studies. MICS was related to significant risk reductions of permanent pacemaker implantation, surgical site infection, and transfusion compared to the sternotomy approach. The robotic approach was associated with a significant increase in re-exploration for bleeding compared to sternotomy. The subanalysis showed that MICS was associated with a significant increase requiring mitral valve reoperation compared to the sternotomy approach (hazard ratio 7.33 [95% CI: 1.54-34.97], P=0.012), while no significant difference was observed between the sternotomy and the robotic approach. Our network meta-analysis demonstrated that MICS was associated with better short-term outcomes compared to the sternotomy approach. Mitral valve reoperation was more frequent with MICS compared with the sternotomy approach after mitral valve repair, while no difference was observed between the sternotomy and robotic approaches.

NEAR-INFRARED SPECTROSCOPY FOR MONITORING DISTAL LIMB PERFUSION DURING PEDIATRIC MINIMAL INVASIVE CARDIAC SURGERY FOR CONGENITAL HEART DEFECTS

Introduction Acute femoral artery occlusion due to remote access bypass (femoral arterial cannulation), is a routine for pediatric minimal invasive cardiac surgery and prevention of leg ischemia is necessary. This technique requires peripheral vessel cross clamping, which may lead to transient perfusion deficit of the lower extremities.Strategies to prevent muscle necrosis or development of compartment syndrome include invasive or non-invasive monitoring of tissue oxygen saturation of involved extremity. A variety of means are utilized, to assess lower extremity (LE) perfusion – including pulse palpation, pulse oximetry, subjective assessment of LE by colour, temperature etc. Regional oxygen saturation measured by near-infrared spectroscopy (NIRS), used as a potential surrogate of cerebral and somatic mixed venous oxygen saturation-is a noninvasive tool to continuously monitor LE perfusion. We sought to evaluate the safety of peripheral arterial cannulation by using NIRS in such subset of patients. Methods We evaluated 50 pediatric patients, weight 10-30kg, age 3-12years, divided in: Group A (N=25), - underwent peripheral femoral artery cannulation for remote access perfusion for MICS, group B (N=25), receive conventional sternotomy incision. All patients were monitored by transcutaneous NIRS (placed on calves of both legs) for quality control of distal leg perfusion during cardiopulmonary bypass. Baseline NIRS value, followed by continuous NIRS values were recorded. Total creatinine kinase (CK) and serum myoglobin levels, mid-thigh and mid -calf circumference (to rule out compartment syndrome), were measured at preoperatively, 6hour and 24hour after surgery. Intra-operatively, all hemodynamic parameters along with blood gas parameters like PH, PO2, PCO2, SCVO2, lactate etc. were recorded at baseline, on bypass, clamp on, clamp off and off bypass period. Total CPB time, ventilation duration, hospital and ICU stay were also recorded. Results The baseline NIRS comparable in group A (72.6±6.86) over cannulated versus (71.76±4.05), contralateral leg, while, in group B, it was (69.96±5.75 vs.69.84±5.50). During clamping of femoral artery in Group A, NIRS dropped to 39.12±5.60 (vs. baseline), while it remained stable in the contralateral leg and group B patients. After successful implantation of the distal leg perfusion, the NIRS normalized to baseline within 5 to 7 minutes. Myoglobin and CK levels increased in both the groups, more so in Group A. There were no clinical side effects from increased CK or myoglobin. None of our patients had residual vascular complications. ±±±± Discussion We speculate that remote CPB with direct femoral artery cannulation can be safely used in pediatric patients- with a body weight 10-30 kg and CPB time less than 60 minutes- without increasing operative morbidity and complications. When prolonged CPB time is expected probably one should change the MICS policy by adding selective distal leg perfusion to minimize the complications

Ministernotomy for Aortic Valve Replacement Versus Conventional Sternotomy, a Choice for a Better outcome

Abstract Background ​ In the era of minimal invasive cardiac surgery, Ministernotomy Aortic valve .replacement have been proposed as an alternative to conventional full sternotomy approach Aim of the Work ​: ​​To evaluate the safety and efficacy of AVR through ministernotomy in comparison to full sternotomy AVR in terms of Cardiac cause mortality, Neurological and .Renal complication​s Patients and Methods ​After gaining the institutional ethical committee approval, the study included all patients who underwent isolated, DE novo, open aortic valve replacement during the period from June 2017 till June 2019 performed by multiple surgeons at cardiothoracic .academy Ain Shams University Results ​ The study included 60 patients; 32 patients performed through full sternotomy (53.3%) and 28 patients through ministernotomy (46.6%).​ ​Post-operative arrhythmias occurred in full sternotomy in 6 cases (18.8%) where in mini-sternotomy, only 3 cases (12%) developed arrhythmias with no significant statistical difference (p value = ​0.558)​. Cerebrovascular stroke was recorded 1 patient (3%) versus 4 cases (14.3%) in the full sternotomy versus the ministernotomy groups respectively with no Statistical difference between the 2 groups (p value = 0.119).​ Postoperative acute renal impairment was recorded​ in 3 cases (9.4%) vs 2 patients (7.1%) in the full sternotomy vs the ministernotomy groups respectively (p value = 0.755). There was no​ mortality in either groups. Mean post-operative Ventilation hours were 17.21hrs with SD ± 11.026 versus 14.97hrs with SD ​± ​6.473 (p value is 0.35) for the full sternotomy versus the ministernotomy groups respectively. Mean blood loss was 305.51ml with SD ± 282.662 versus 230.36ml with SD ​± ​247.708 (p value is 0.277) for the full versus the ministernotomy groups respectively. Mean units of blood transfused was 2.31Units with SD ​± ​0.926 versus 1.14Units with SD ​±​ 0.591 in the full sternotomy versus the ministernotomy groups with high statistical significance between both groups (p value less than 0.01). Mean ICU stay was 2.66 days with SD ​±​ 0.915 and was 3.1days with SD ​±​ 2.743 (p .value is 0.424) for the full sternotomy versus the ministernotomy groups respectively Conclusion ​ Ministernotomy Aortic valve replacement was found to be a safe procedure​ compared to full sternotomy approach. Patients who had their surgery through the mini approach had less amount of blood loss, blood transfusion requirements, ventilation time which all led to less duration of ICU and hospital stay, resulting in a better outcome for the .patients

Experience of Minimal Invasive Cardiac Surgery for repair of Atrial Septal Defects- A Single Center Study

Background: Atrial Septal Defects (ASD) can be closed surgically using conventional midline sternotomy or minimal invasive technique. This study was done to evaluate the outcome and safety of the minimal invasive cardiac surgical (MICS) approach using right vertical infra axillary incision (RVAI) for the repair of ASD. Methods: We performed a prospective observational cross-sectional analysis on 50 patients who were diagnosed as ASD of various types and not amenable to device closure. Their surgery was done RVAI using central cardiopulmonary bypass. Outcome of the study was evaluated using the following variables: length of the incision, satisfaction of patients, mortality, infection of surgical site, blood transfusion, duration of total operation, intensive care unit (ICU) stay, mechanical ventilation, hospital stay and aortic occlusion. Operations were done between December 2013 to December 2020. All the recruited patients were treated through RVAI as per patient’s choice. Results: Mean age was 11.4± 6.4 years. 18(36%) were male and 32(64%) were female. Body weight ranged from 10 to 65 kg. Mean length of incision was 6.2±0.8 cm. Mean aortic occlusion time was 42±14 min. ASD closed directly, using autologous treated pericardial patch or dacron patch. Mean total operation time was 4.08±0.6 hours and mean mechanical ventilation time was 8.3±5 hours. Average ICU stay was 35.6±6 hours and total hospital stay was 7.2±0.9 days. There was no significant blood loss. Only 10 patients required intravenous (IV) analgesics in the post-operative period. One patient required re-exploration, one conversion to median sternotomy and one suffered from superficial skin infection. There were no operative or late mortalities. Patient satisfaction was excellent. Conclusions: MICS technique using RVAI for surgical repair of ASD revealed a safe procedure and could be performed with excellent cosmetic and clinical outcomes. It provided a good alternative to the standard median sternotomy. Cardiovasc j 2021; 14(1): 37-43

The Impact of Biomedical Engineering on the Development of Minimally Invasive Cardio-Thoracic Surgery.

(1) We describe the boundary conditions for minimally invasive cardiac surgery (MICS) with the aim to reduce procedure-related patient injury and discomfort. (2) The analysis of the MICS work process and its demand for improved tools and devices is followed by a description of the relevant sub-specialties of bio-medical engineering: electronics, biomechanics, and materials sciences. (3) Innovations can represent a desired adaptation of an existing work process or a radical redesign of procedure and devices such as in transcutaneous procedures. Focused interaction between engineers, industry, and surgeons is always mandatory (i.e., a therapeutic alliance for addressing ‘unmet patient or professional needs’. (4) Novel techniques in MICS lean heavily on usability and safe and effective use in dedicated hands. Therefore, the use of training and simulation models should enable skills selection, a safe learning curve, and maintenance of proficiency. (5) The critical technical steps and cost–benefit trade-offs during the journey from invention to application will be explained. Business considerations such as time-to-market and returns on investment do shape the cost–benefit room for commercial use of technology. Proof of clinical safety and effectiveness by physicians remains important, but establishing the technical reliability of MICS tools and warranting appropriate surgical skills come first.

Sex-specific differences and postoperative outcomes of minimally invasive and sternotomy valve surgery.

OBJECTIVESFemale sex is an established risk factor for postoperative complications after heart surgery, but the influence of sex on outcomes after minimally invasive cardiac surgery (MICS) for valvular replacement/repair remains controversial. We examined whether the role of sex as a risk factor varies by surgical approach [MICS vs conventional sternotomy (ST)] and further assessed outcomes among female patients including in-hospital mortality and postoperative complications by surgical approach.METHODSWe analysed data from a multicentre registry for patients who underwent isolated aortic valve and mitral surgery with MICS or ST. The primary outcome was in-hospital mortality. Propensity score matching was used to minimize between-group differences.RESULTSAmong the 15 155 patients included in the study, 7674 underwent MICS (50.6%). Female sex was equally distributed in the MICS and ST groups (47.3% vs 47.6%, respectively). Risk for surgery was higher in the ST group than in the MICS group {EuroSCORE II: 4.0 [standard deviation (SD): 6.8] vs 3.7 [SD: 6.4]; P = 0.005}, including among female patients only [ST vs MICS 4.6 (SD: 6.9) vs 4.2 (SD: 6.3); P = 0.04]. Mortality did not significantly vary by procedure among women [MICS vs ST, 2.4% vs 2.8%; hazard ratio 1.09, 95% confidence interval 0.71–1.73; P (surgical approach × sex) = 0.51]. The results also did not vary after adjusting for confounders.CONCLUSIONSFemale sex was associated with higher mortality in patients undergoing valve surgery, regardless of surgical approach. In female patients, MICS did not provide any benefits over ST in terms of in-hospital deaths or postoperative complications.Subject collection117, 125.

A survey of minimally invasive cardiac surgery during the COVID-19 pandemic.

Lack of scientific data on the feasibility and safety of minimally invasive cardiac surgery (MICS) during the COVID-19 pandemic has made clinical decision making challenging. This survey aimed to appraise MICS activity in UK cardiac units and establish a consensus amongst front-line MICS surgeons regarding standard best MICS practise during the pandemic. An online questionnaire was designed through the 'googleforms' platform. Responses were received from 24 out of 28 surgeons approached (85.7%), across 17 cardiac units. There was a strong consensus against a higher risk of conversion from minimally invasive to full sternotomy (92%; n = 22) nor there is increased infection (79%; n = 19) or bleeding (96%; n = 23) with MICS compared to full sternotomy during the pandemic. The majority of respondents (67%; n = 16) felt that it was safe to perform MICS during COVID-19, and that it should not be halted (71%; n = 17). London cardiac units experienced a decrease in MICS (60%; n = 6), whereas non-London units saw no reduction. All London MICS surgeons wore an FP3 mask compared to 62% (n = 8) of non-London MICS surgeons, 23% (n = 3) of which only wore a surgical mask. London MICS surgeons felt that routine double gloving should be done (60%; n = 6) whereas non-London MICS surgeons held a strong consensus that it should not (92%; n = 12). Whilst more robust evidence on the effect of COVID-19 on MICS is awaited, this survey provides interesting insights for clinical decision-making regarding MICS and aids to facilitate the development of standardised MICS guidelines for an effective response during future pandemics.

Variation in ascending thoracic aorta position

Background: There is no evidence in current literature that demonstrates the prevalence of ascending thoracic aortic variation in relation to the sternum in the general, or diseased population. This measurement has become an important factor in decision-making for Trans- Catheter Aortic Valve Implantation (TAVI) and Minimally Invasive Cardiac Surgery (MICS). Methods: We conducted a cross-sectional study in Cape Town, South Africa. We evaluated the Thoracic CT scans of pre-selected TAVI patients (n=25) and compared these to Thoracic CT scans from the same general population (n=100). Three parameters of ascending thoracic aorta variations were measured. Results: Mean aorta distance from sternum was 28.01mm (95% CI: 24.56 - 31.48) in cases and 27.34mm (95% CI: 25.49 - 29.20) in controls (p&lt;0.001). The mean position of the aorta relative to the sternum, favoured the aorta being less than 50% of its diameter to the right, in both groups. Aorto-ventricular angle showed a mean angle (degrees) of 47.92 (95% CI: 44.36 - 51.23) in cases and 37.06 (95% CI: 35.03 - 39.09) in controls. Subgroup analysis for age &gt;60 years revealed no difference between groups (p=0.314). An overall linear relationship of aortoventricular angle, compared to age, was demonstrated. Conclusion: Statistical analysis of ascending thoracic aorta position indicates that patients presenting for aortic valve surgery, especially older patients (&gt;70 years), have favourable anatomy for MICS through a right thoracotomy. The aortic distance from the sternum was larger in the exposed group &gt;60 years. Aortic valve disease does not cause variation in aorto-ventricular angle. The aorto-ventricular angle increases linearly with age, in both groups.

Imaging evaluation of continuous extrapleural intercostal nerve block for minimally invasive cardiac surgery: a case report

BackgroundSpinal nerve block is difficult with minimally invasive cardiac surgery (MICS), because of the risk of serious bleeding complications due to full heparinization. Continuous extrapleural intercostal nerve block (CEINB) is a postoperative pain treatment for intercostal thoracotomy, with fewer complications. Here, we report a case in which imaging evaluation of CEINB with contrast medium was conducted to anatomically confirm the spread of local anesthetics after MICS.Case presentationA 65-year-old woman with severe mitral regurgitation underwent mitral valve plasty under general anesthesia via right-sided mini-thoracotomy. A CEINB catheter was placed before the incision was closed, without creating a conventional extrapleural pocket. We conducted an imaging evaluation with a contrast medium via the inserted catheter and confirmed sufficient spread around the intercostal nerve area. In addition, postoperative pain was well controlled by the nerve block.ConclusionsImaging evaluation of CEINB with contrast medium could increase analgesic quality and decrease complications post-MICS.

Right Mini-Thoracotomy versus Standard Sternotomy for Surgical Excision of Atrial Myxomas

Introduction: Atrial myxomas are rare benign tumors; causing obstructive or embolic complications, or even death, depending on their site and size. Therefore, once diagnosed, it should be surgically resected. Atrial myxomas are present about 75% in left atrium (LA) and about 15% in right atrium (RA). Early diagnosis is a challenge because of nonspecific manifestations, and sometimes is asymptomatic and may be discovered accidentally during transthoracic echography (TTE).Minimally invasive cardiac surgery (MICS) has benefits over sternotomy include cosmetically, less pain, and shorter total hospital stay. Materials and Methods:Between January 2011 to December 2020, (50) patients [30 Sternotomy, 20 MICS] underwent surgery for isolated resection of cardiac myxoma. We reported outcomes; cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, conversion to median sternotomy (ST), total hospital stay, complications (stroke, renal failure, respiratory failure, reoperation, and infection), pain, patient¢s satisfaction, recurrence and survival. Follow-up time was from 6-months to 3-years. Results: There is no significant difference in CPB or cross-clamp time between groups. No minimal invasive (MI) cases required conversion to a median ST. Total hospital stay is shorter in the MI group by 2.2 days (p-value = 0.045). No differences present in morbidity or mortality between two groups. Conclusions: Surgical resection of atrial myxoma resection by minimal invasive approach is safe, feasible, and favored over sternotomy

Unilateral Pulmonary Edema After Robotically Assisted Mitral Valve Repair Requiring Veno-Venous Extracorporeal Membrane Oxygenation

Unilateral pulmonary edema (UPE) is an uncommon yet potentially life-threatening complication of minimally invasive cardiac surgery (MICS). Most frequently described after robotically assisted mitral valve (MV) repair, it is characterized by right lung edema, hypoxemia, hypercapnia, pulmonary hypertension, and hemodynamic instability beginning minutes-to-hours after separation from cardiopulmonary bypass (CPB). The authors describe a severe case with refractory hypoxemia requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO) after robotically assisted MV repair.

Economic impact of enhanced recovery after surgery protocol in minimally invasive cardiac surgery

BackgroundERAS (Enhanced Recovery After Surgery) is a multidisciplinary and integrative approach with the goal of optimizing the postoperative recovery. We aimed to analyze the economic impact of a newly established ERAS protocol in minimally invasive heart valve surgery at our institution.MethodsERAS protocol was implemented in 61 consecutive patients who were referred for elective minimally-invasive aortic or mitral valve surgery, between February 1, 2018 and March 31, 2019 (ERAS-group). Another 69 patients who underwent elective minimally-invasive heart valve surgery during the same time period were managed according to the hospital standards (Control-group). A detailed cost comparison analysis was carried out from a hospital perspective using a micro-costing approach.ResultsThe total in-hospital stay was significantly shorter in the ERAS-group compared to the Control-group (6.1 ± 2.6 vs 7.7 ± 3.8 days; p = 0.008) resulting in significant cost savings of €1087.2 per patient (p = 0.003). Due to the intensified physiotherapy in the ERAS protocol, the costs for physiotherapy were €94.3 higher compared to the Control-group (p < 0.001). The total costs in the ERAS cohort were €11,200.0 ± 3029.6/patient compared to € 13,109.8 ± 4527.5/patient in the Control-Group resulting in cost savings of €1909.8 patient due to the implementation of the ERAS protocol (p = 0.006).ConclusionImplementation of an ERAS-protocol in minimally-invasive cardiac surgery can be carried out safely with a fast postoperative recovery of the patient. ERAS results in a financial benefit of up to €1909 per patient and therefore will play a key role in modern cardiac surgery in the near future.