Minimal Invasive Mitral Valve Research Articles

Serial Cardiac Magnetic Resonance Imaging in Patients with Mitral Valve Prolapse-A Single-Center Retrospective Registry.

Background: Mitral valve prolapse (MVP) and mitral annular disjunction (MAD) are common valvular abnormalities that have been associated with ventricular arrhythmias (VA). Cardiac magnetic resonance imaging (CMR) has a key role in risk stratification of VA, including assessment of late gadolinium enhancement (LGE). Methods: Single-center retrospective analysis of patients with MVP or MAD who had >1 CMR and >1 24 h Holter registration available. Data are presented in detail, including evolution of VA and presence of LGE over time. Results: A total of twelve patients had repeated CMR and Holter registrations available, of which in four (33%) patients, it was conducted before and after minimal invasive mitral valve repair (MVR). After a median of 4.7 years, four out of eight (50%) patients without surgical intervention had new areas of LGE. New LGE was observed in the papillary muscles and the mid to basal inferolateral wall. In four patients, presenting with syncope or high-risk non-sustained ventricular tachycardia (VT), programmed ventricular stimulation was performed and in two (50%), sustained monomorphic VT was easily inducible. In two patients who underwent MVR, new LGE was observed in the basal inferolateral wall of which one presented with an increased burden of VA. Conclusions: In patients with MVP and MAD, repeat CMR may show new LGE in a small subset of patients, even shortly after MVR. A subgroup of patients who presented with an increase in VA burden showed new LGE upon repeat CMR. VA in patients with MVP and MAD are part of a heterogeneous spectrum that requires further investigation to establish risk stratification strategies.

Discussion to: Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

Discussion to: Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

Alternative minimally invasive surgical explantation techniques for failed transcatheter mitral valve repair devices.

The use of transcatheter mitral valve repair (TMVr) devices is increasing in elderly and high-risk patients. However, the increasing number of patients with recurrent mitral regurgitation (MR) has confronted surgeons with the issue of how to explant the devices and whether the mitral valve should be repaired or replaced. The aim of the study is to summarize our clinical experience with the explantation of different TMVr devices and to provide alternative surgical techniques that can be performed in different clinical scenarios. A simulator system including a dummy valve representing native valves was used to create video documentation and to develop alternative surgical methods for clip explantation. Moreover, the clip explantation techniques were shown in 2 patients undergoing minimally-invasive mitral valve repair after a failed TMVr. Alternative explantation techniques were described for each TMVr device; 2 techniques for MitraClip and 3 techniques for PASCAL (Precision Transcatheter Valve Repair System), which may be adjusted for each individual according to the underlying valve pathology and the degree of device encapsulation. The patients were discharged without residual MR and remained MR free at the follow-up. Transcatheter edge-to-edge repair devices can be surgically explanted without damaging the MV leaflets. Removal of each device may require a different technique tailored to the degree of device encapsulation and valve pathology. Increasing experience may facilitate repair in patients with recurrent MR after TMVr.

Success of Minimally Invasive Mitral Valve Repair: A Multicentre Experience

Minimally invasive mitral valve (MIMV) surgery may be associated with improved cosmesis, reduced postoperative pain, less blood loss, fewer infections, and shorter length of stay. Thirty-day morbidity and mortality has been reported as low as 0–1.1%. Transcatheter MV replacement 30-day mortality has been reported up to 23% and up to 14% in The Twelve Intrepid TMVR Pilot Study. This study aimed to assess the success of MIMV repair and how many of these progress to replacement.

When Minimal Becomes Maximal: The Decision to Convert

Since A. Carpentier published the first report using video-assisted minimally invasive mitral valve (MIMV) repair in 1996, this technique has undergone a significant evolution. Mini-thoracotomy ± rib-spreading, mini-incision, and fully endoscopic techniques are examples of how MIMV surgery is now performed. As there is a well-known learning curve, which prevents some surgeons from adopting MIMV surgery, the rate of conversion to full sternotomy has been reported to be <1% in experienced centres. The key factor of “patient selection” remains and there are absolute and relative contraindications to performing MIMV surgery to prevent complications. However, if complications occur, timing and adequate decision-making to convert to partial or full sternotomy are very important, as morbidity and mortality remain high if surgeons must convert.

Early outcomes of minimally invasive mitral and tricuspid valve surgery in obese patients

Background: Minimal invasive valve surgery is the new trend in cardiac surgery. Many obstacles are present to increase the number of cases operated on with minimally invasive surgery. Minimal invasive surgery is technically demanding in obese patients with uncertain outcomes. In this study, we compared minimal invasive mitral and tricuspid valve surgery (MIVS) in obese patients with high BMI (body mass index) to normal BMI.&#x0D; Method: We included 240 cases who underwent MIVS. These cases were divided into two groups. Group I (n=120) included patients with BMI &gt;30 Kg/m2, and Group II (n=120) had BMI ≤30 Kg/m2.&#x0D; Result: There was no in-hospital mortality in both group. Postoperative wound infection was nonsignificantly higher in Group I (9 (7.5%) vs. 2 (1.67%); P= 0.059). Drainage (450± 112 vs. 240± 230 ml; P&lt;0.001), mechanical ventilation time (13.4± 1.3 vs. 6.4± 6.8 h; P&lt;0.001), and ICU stay (2± 0.4 vs. 3.5± 1.3 days, P&lt;0.001) were significantly higher in Group I. New onset atrial fibrillation was significantly higher in obese patients (P= 0.029). There were no differences between both groups in other outcomes.&#x0D; Conclusion: Minimally invasive surgery in obese patients had satisfactory outcomes compared to those with normal BMI. Obesity should not be considered a contraindication for minimally invasive surgery.

Early Outcome of Mitral Valve Surgery comparing Minimally Invasive Versus Standard Median Sternotomy Approach

Minimal invasive mitral valve surgery (MIMVS) aims to avoid complications of SMS like, bleeding, postoperative pain, and sternal wound infection. It provides better cosmesis and early recovery. The aim of this study is to evaluate early clinical outcome of MIMVS.

Antegrade axillary arterial perfusion in 3D endoscopic minimally-invasive mitral valve surgery.

BackgroundMinimally-invasive (MIS) mitral valve (MV) surgery has become standard therapy in many cardiac surgery centers. While femoral arterial perfusion is the preferred cannulation strategy in MIS mitral valve surgery, retrograde arterial perfusion is known to be associated with an increased risk for cerebral atheroembolism, particularly in atherosclerosis patients. Therefore, antegrade perfusion may be beneficial in such cases. This analysis aimed to compare outcomes of antegrade axillary vs. retrograde femoral perfusion in the MIS mitral valve surgery.MethodsThis analysis includes 50 consecutive patients who underwent MIS between 2016 and 2020 using arterial cannulation of right axillary artery (Group A) due to severe aortic arteriosclerosis. Perioperative outcomes of the study group were compared with a historical control group of retrograde femoral perfusion (Group F) which was adjusted for age and gender (n = 50). Primary endpoint of the study was in-hospital mortality and perioperative cerebrovascular events.ResultsPatients in group A had a significantly higher perioperative risk as compared to Group F (EuroSCORE II: 3.9 ± 2.5 vs. 1.6 ± 1.5; p = 0.001; STS-Score: 2.1 ± 1.4 vs. 1.3 ± 0.6; p = 0.023). Cardiopulmonary bypass time (group A: 172 ± 46; group F: 178 ± 51 min; p = 0.627) and duration of surgery (group A: 260 ± 65; group F: 257 ± 69 min; p = 0.870) were similar. However, aortic cross clamp time was significantly shorter in group A as compared to group F (86 ± 20 vs. 111 ± 29 min, p < 0.001). There was no perioperative stroke in either groups. In-hospital mortality was similar in both groups (group A: 1 patient; group F: 0 patients; p = 0.289). In group A, one patient required central aortic repair due to intraoperative aortic dissection. No further cardiovascular events occurred in Group A patients.ConclusionSelective use of antegrade axillary artery perfusion in patients with systemic atherosclerosis shows similar in-hospital outcomes as compared to lower risk patients undergoing retrograde femoral perfusion. Patients with higher perioperative risk and severe atherosclerosis can be safely treated via the minimally invasive approach with antegrade axillary perfusion.

Early Outcome of Mitral Valve Surgery comparing Minimally Invasive versus Standard Median Sternotomy Approach

Background: This study compares our experience of early outcome of mitral valve surgery (MVS) after minimally invasive (MI) versus standard median sternotomy (SMS) approach. Objective: Minimal invasive mitral valve surgery (MIMVS) aims to avoid complications of SMS like; bleeding, postoperative pain, and sternal wound infection. It provides better cosmesis and early recovery. The aim of this study is to evaluate early clinical outcome of MIMVS. Patient and Method: It is prospective comparative cohort study in adult patients with mitral valve disease who perform MVS using either MI or SMS. From January 2020 to December 2021, early outcome of MVS between [120 patients] MI group through right mini-thoracotomy (RMT) with CPB peripheral cannulation and [120 patients] SMS group are compared. Result: Females are more in MIMVS (80%). ACC and CPB time are longer in MIMVS than SMS (118±15.5 vs 74.4±32.3, 155±28.5 vs 115±48.8). Tricuspid repair and left atrial appendage (LAA) occlusion are performed only in SMS. Blood loss is lesser in MIMVS (250 ± 60.6 ml) than in SMS (550 ± 230 ml). Blood transfusion required (0.1 ± 0.53) in MIMVS, and (0.9 ± 0.7) in SMS. Re-exploration for bleeding is required in (4) cases of SMS. Mechanical ventilation time is shorter in MIMVS (6.4 ± 1.3) than in SMS (12.4 ± 6.8). ICU duration and hospital stay are shorter in MIMVS than SMS (2±0.4 vs 3.5±1.3, 7.2±1.3 vs 12±0.5). Wound infections present in (20) cases of SMS. Spirometric studies in MIMVS reveal better postoperative pulmonary functions than SMS group. Pain Visual Analog Score at discharge is better in MIMVS (1.4 ± 0.6) than in SMS (8.5 ± 1.5). There is no hospital mortality in both groups. Conclusion: Minimal invasive mitral valve surgery is a safe procedure and improves cosmesis and patient’s satisfaction.

Minimally Invasive versus Conventional Mitral Valve Surgery: Procedures and Early Outcomes

Background: Minimal invasive mitral valve surgery gained wide acceptance. However, criticism continuous about its ability to replace the conventional full sternotomy technique.Aim of the work: The study aimed to compare between the full sternotomy and less invasive approaches for mitral valve surgery.Patients and Methods: The study recruited 100 patients. They were allocated to one of two equal groups [the traditional and minimal invasive approach]. All patients were thoroughly evaluated by history taking, physical examination, laboratory and ancillary radiological investigations. Assessment included incision length, weaning events, aortic cross clamp time, total bypass and operative times, rate of conversion from minimally invasive technique to full sternotomy. In surgical intensive care unit, ventilation hours, post-operative pain and need for analgesia, re-exploration for bleeding, blood loss and blood transfusion, and any complications were documented.Results: Preoperative New York Heart Association [NYHA] class was significantly different between groups A and B. But, no significant difference was reported for patient demographic or preoperative data. The incision length and cross clamp time was shorter in A than B group [6.56±1.88 cm, 61.78±35.91 minutes’ vs 12.54±1.78 cm, and 78.08±36.24 minutes, respectively]. Otherwise, the cannulation, bypass, operative times were significantly longer among group A. The ventilation, ICU stay, hospital stay, bleeding, serum creatinine and pain scores were significantly lower among group A. the postoperative events were comparable between both groups with slight increase of neurological events in A group [3 cases] than B group [2 cases]. At 6 months, both groups yielded non-significant difference, regardless of better outcome at direct postoperative time.Conclusion: Minimal invasive mitral valve surgery had a good short and mid-term outcome as the conventional sternotomy approach. It could replace the conventional approach as a gold-standard for mitral valve surgery.

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive mitral valve surgery after previous sternotomy: A propensity-matched analysis.

Although the incidence of mitral valve (MV) surgery after previous open-heart surgery is increasing, there is no consensus regarding the optimal surgical approach. Reoperative MV surgery is most commonly performed via sternotomy (ST). We sought to determine whether minimally-invasive (MIS) reoperative MV surgery is safe and feasible. All patients with a history of ST undergoing MV surgery with or without concomitant tricuspid or atrial fibrillation surgery at a single institution from 2007 to 2018 were retrospectively reviewed. ST and MIS approaches were compared using propensity-matched analysis. The coprimary endpoints were operative mortality and 1-year survival, and secondary endpoints were operative complications and length of stay. A total of 305 isolated MV reoperations were performed: 199 (65%) MIS and 106 (35%) ST. MIS patients were older than ST patients (71 [63, 76.5] vs. 66 [56, 72] years, p < .01), more likely to have undergone prior coronary artery bypass grafting (57% vs. 27%, p < .01), and less likely to have had prior valve surgery (55% vs. 78%, p < .01). In unmatched comparisons, operative mortality was significantly lower among MIS patients (3.0% vs. 8.5%, p = .04), but 1-year mortality was similar (14.4% vs. 15.6%, p = .8). After propensity matching, 88 pairs had excellent balance across baseline characteristics. Mortality was similar among MIS and ST patients at 30 days (3.4% vs. 8%, p = .19) and 1 year (15.9% vs. 16.5%, p = .9). RBC and fresh frozen plasma transfusions were significantly lower in the MIS group (p < .01). A minimally invasive approach is a safe alternative in patients with prior ST undergoing MV surgery.

Outcome of Unilateral Pulmonary Edema after Minimal-Invasive Mitral Valve Surgery: 10-Year Follow-Up

The study was approved by the institutional review board (IRB) at the University Medical Center Campus Kiel, Kiel, Germany (reference number: AZ D 559/18) and registered at the German Clinical Trials Register (reference number: DRKS00022222). Objective. Unilateral pulmonary edema (UPE) is a complication after minimally invasive mitral valve surgery (MIMVS). We analyzed the impact of this complication on the short- and long-term outcome over a 10-year period. Methods. We retrospectively observed 393 MIMVS patients between 01/2009 and 12/2019. The primary endpoint was a radiographically and clinically defined UPE within the first postoperative 24 h, secondary endpoints were 30-day and long-term mortality and the percentage of patients requiring ECLS. Risk factors for UPE incidence were evaluated by logistic regression, and risk factors for mortality in the follow-up period were assessed by Cox regression. Results. Median EuroSCORE II reached 0.98% in the complete MIMVS group. Combined 30-day and in-hospital mortality after MIMVS was 2.0% with a 95, 93 and 77% survival rate after 1, 3 and 10 years. Seventy-two (18.3%) of 393 patients developed a UPE 24 h after surgery. Six patients (8.3%) with UPE required an extracorporeal life-support system. Logistic regression analysis identified a higher creatinine level, a worse LV function, pulmonary hypertension, intraoperative transfusion and a longer aortic clamp time as predictors for UPE. Combined in hospital mortality and 30-day mortality was slightly but not significantly higher in the UPE group (4.2 vs. 1.6%; p = 0.17). Predictors for mortality during follow-up were age ≥ 70 years, impaired RVF, COPD, drainage loss ≥ 800 mL and length of ventilation ≥ 48 h. During a median follow-up of 4.6 years, comparable survival between UPE and non-UPE patients was seen in our analysis after 5 years (89 vs. 88%; p = 0.98). Conclusions. In-hospital outcome with UPE after MIMVS was not significantly worse compared to non-UPE patients, and no differences were observed in the long-term follow-up. However, prolonged aortic clamp time, worse renal and left ventricular function, pulmonary hypertension and transfusion are associated with UPE.

Mitral Repair for Mitral Prolapse: Comparison of Thoracoscopic Minimally-Invasive and Conventional Approaches Using Propensity Score

Objective: Surgical repair remains the standard treatment for severe mitral regurgitation (MR) due to mitral prolapse. Minimally-invasive mitral valve surgery (MIMVS) has been increasingly performed but still is the minority, with lack of solid evidence on its superiority over conventional surgery. Our objectives were to compare the results of MIMVS and conventional surgery. Methods: Retrospective review of all patients treated in our center with degenerative severe MR (November 2011 – May 2020). Patients with previous mitral surgery and those requiring concomitant procedures other than atrial fibrillation ablation were excluded. Two groups were compared: MIMVS (minimally invasive surgery) and Open (full median sternotomy), in a cohort of matched (1:1; nearest neighbor) pairs using propensity score (PS) methods. Results: 286 consecutive patients met the inclusion criteria (MIMVS:183, Open:103). There were no significant differences preoperatively, except for lower age, NYHA III-IV and EuroSCOREII in the MIMVS group. In both groups, around 40% of patients presented with anterior or bileaflet prolapse, with no differences in repair techniques used. After PS matching, a cohort of 93 matched pairs was selected and all basal differences were balanced. Comparisons showed that despite bypass and cross-clamp times were higher (+32 and +21m; p<0.001), MIMVS presented shorter mechanical ventilation (0 vs. 6h; p<0.01), ICU stay (1.8 vs. 2.5d; p=0.02), higher hemoglobin (11 vs. 10mg/dL; p<0.02) and less renal failure (1 vs. 8%; p:0.03). There were no differences in mortality, repair rate or MR grade at discharge. During follow-up (median 2.8 years), there were no significant differences in the degree of recurrent MR and reoperation. Conclusions: Surgical repair of mitral prolapse is possible in most cases with low perioperative morbimortality and excellent mid-term results. MIMVS can be performed without compromising perioperative outcomes, repair rate and durability, while providing shorter ICU and mechanical ventilation duration, less blood loss and renal failure.

Minimally-invasive mitral valve repair of symmetric and asymmetric Barlow\xb4s disease

ObjectivesBarlow´s disease represents a wide spectrum of mitral valve pathologies associated with regurgitation (MR), excess leaflet tissue, and prolapse. Repair strategies range from complex repairs with annuloplasty plus neochords through resection to annuloplasty-only. The latter requires symmetric prolapse patterns and central regurgitant jets. We aimed to assess repair success and durability, survival, and intraoperative outcomes with symmetric and asymmetric Barlow’s disease.MethodsBetween 09/10 and 03/20, 103 patients (of 1939 with mitral valve surgery) presented with Barlow´s disease. All received surgery through mini-thoracotomy with annuloplasty plus neochords (n = 71) or annuloplasty-only (n = 31). One valve was replaced for endocarditis (repair rate: 99%).ResultsAnnuloplasty-only patients were older (64 ± 16 vs. 55 ± 11 years, p = 0.008) and presented with higher risk (EuroSCORE II: 4.2 ± 4.9 vs. 1.6 ± 1.7, p = 0.007). Annuloplasty-only patients had shorter cross-clamp times (53 ± 18 min vs. 76 ± 23 min, p < 0.001) and received more tricuspid annuloplasty (15.5% vs. 48.4%, p < 0.001). Operating times were similar (170 ± 41 min vs. 164 ± 35, p = 0.455). In three patients, annuloplasty-only caused intraoperative systolic anterior motion (SAM), which was fully resolved by neochords to the posterior leaflet. There were no conversions to sternotomy or deaths at 30-days. Three patients required reoperation for recurrent MR (at 25 days, 2.8 and 7.8 years). At the latest follow-up, there was no MR in 81.4%, mild in 14.7%, and moderate in 2.9%. Three patients died due to non-cardiac reasons. Surviving patients report the absence of relevant symptoms.ConclusionsMinimally-invasive Barlow’s repair is safe with good durability. Annuloplasty-only may be a simple solution for complex but symmetric pathologies. However, it may carry an increased risk of intraoperative SAM.

Postoperative Outcomes of Minimally Invasive versus Conventional Mitral Valve Repair; A Randomized Study

Background: Minimally invasive mitral valve surgery (MIMVS) is associated with less surgical trauma. However, its advantages over the conventional approach are controversial. This study aims to compare the early postoperative pain, hospital stay, and pulmonary function between minimally invasive and conventional mitral repair.&#x0D; Methods: Fifty patients with non-ischemic mitral valve disease who had mitral valve repair between 2017 and 2019 were included in the study. Patients were randomly divided into two equal groups. Group A (n=25) included patients who had minimally invasive mitral valve repair via anterolateral mini-thoracotomy with video assistance, and Group B (n=25) included patients who had mitral valve repair via median sternotomy.&#x0D; Results: The cross-clamp (99.45±16.01 vs. 87. 5±19.16 min; p= 0.058) and the total bypass times (134.08±27.38 vs. 120.71±22.18 min; p= 0.35) were nonsignificantly longer in Group A. Operative time was significantly longer in Group A (207.08±44.31 vs. 173.54±28.25 min; p= 0.001). The ICU stay in Group (A) was 2.58±1.44 days, and in Group (B), the ICU stay was 3.75±1.77 days (p= 0.001). The hospital stay was 7.87±1.59 days in Group A, and 14.5 ±5.05 days in Group B (P&lt;0.001). Postoperative FEV1 was 2.06±0.63 L in Group A and 1.39±0.43 L in Group B (p= 0.001). There was no difference in postoperative ejection fraction between both groups (p= 0.9).&#x0D; Conclusion: Minimal invasive mitral valve repair could reduce postoperative pain, length of ICU, and hospital stay and improve the postoperative respiratory function when compared to the conventional approach.

Resurgence of the edge-to-edge repair of the mitral valve.

To provide a critical review of the application and outcomes of surgical edge-to-edge (E2E) or Alfieri repair for mitral valvulopathy. The E2E repair is a surgical technique to address mitral regurgitation, particularly suited when the responsible mechanism is bileaflet prolapse combined with enlarged annular area. It can also be used for a range of mitral valve pathologies. Surgically, the technique has been employed as a bailout for unsuccessful repair including residual mitral regurgitation because of systolic anterior motion (SAM). E2E repair should be accompanied by a ring annuloplasty for long-term repair durability. The simplicity of this approach makes it an ideal strategy during minimally-invasive mitral valve repair. It may also be performed via a transaortic approach at the time of aortic valve surgery to address less-than-severe mitral regurgitation or to address residual SAM following myectomy for hypertrophic obstructive cardiomyopathy. We review the surgical indication, potential complications including risk of mitral stenosis and the long-term outcomes of E2E repair. The E2E surgical repair is a simple and effective surgical strategy to address a wide range of mitral regurgitation. This is an important technique in the surgical armamentarium especially in cases of minimally-invasive mitral valve surgery.

Cost Analysis of Minimally Invasive Mitral Valve Surgery in the UK National Health Service

In the UK National Health Service, finite resources make the adoption of minimally invasive (MI) mitral valve surgery challenging unless greater operative costs (vs sternotomy [ST]) are balanced by postoperative savings. This study examined whether the cost analysis now became unfavorable. All patients (n= 380) undergoing isolated mitral valve surgery with or without a maze procedure over a 3-year period by either MI or ST approaches were included. Propensity matching (2 cohorts, 1:1 matched;, n= 75 per group) and multivariable regression were used to assess for the effect on cost. Cost data were prospectively collected from Service Line Reporting and reported in Sterling (£) as median (interquartile range [IQR]). Matched data revealed that total hospital costs were equivalent (MI vs ST, £16,672 [IQR, £15,044, £20,611] vs £15,875 [IQR, £12,281, £20,687]; P .33). Three of 15 costing pools were significantly different: operative costs were higher for the MI group (MI vs ST, £7458 [IQR, £6738, £8286] vs £5596 iIQR, £4204, £6992]; P < .001), whereas ward costs (boarding, nursing) (MI vs ST, £1464 [IQR, £1146, £1864] vs £1733 [IQR, £1403, £2445] P= .006) and pharmacy services (MI vs ST, £187 [IQR, £140, £239] vs £244 [IQR, £179, £375] P < .001) were lower for the MI group. Hospital stay was shorter in the MI group (MI vs ST, 6 days [IQR, 5, 8 days] vs 8 days [IQR, 6, 11 days]; P < .001). Multivariable regression produced similar findings. There was no difference in overall hospital cost between MI and ST mitral valve surgery: higher operative costs of MI surgery were offset by lower postoperative costs, with a 2-day shorter hospital stay.

Effectiveness of surgical closure of left atrial appendage during minimally invasive mitral valve surgery.

Left atrial appendage closure (LAAC) reduces the risk of stroke in patients with atrialfibrillation. It can be performed surgically from the inside of the left atrium or from the outside. Stapling or clipping devices can also be used from the outside. Despite providing an excellent interior view of the appendage, those techniques cannot be implemented during minimally invasive mitral valve surgery conducted through right‑sided minithoracotomy. This study aimed to assess the effectiveness of surgical closure of the left atrial appendage from the inside during minimally invasive mitral valve surgery. A total of 50 patients with mitral valve disease and atrial fibrillation who underwent minimallyinvasive mitral valve surgery and LAACbetween 2012 and 2017 were included in this study. The appendagewas closed from the inside using a continuous suture. After a median follow‑up of 1.6 years after surgery, 19 patients were examined by transthoracic and transesophageal echocardiography (TEE). Transesophageal echocardiography was performed to assess whether the appendage had been effectively closed. When any leakage was suspected, cardiac computed tomography was performed. In 19 patients, TEE was performed at 0.5 to 5 years after the surgery. A single patient did not tolerate TEE, and minimal leakage was suspected in 2 patients. All 3 individuals underwent computed tomography examination, which confirmed leakage in a single patient. Surgical LAACduring minimally invasive mitral valve surgery through right minithoracotomyis an effective technique that provides durable results.

Establishment of an enhanced recovery after surgery protocol in minimally invasive heart valve surgery.

Protocols for “Enhanced recovery after surgery (ERAS)” are on the rise in different surgical disciplines and represent one of the most important recent advancements in perioperative medical care. In cardiac surgery, only few ERAS protocols have been described in the past. At University Heart Center Hamburg, Germany, we invented an ERAS protocol for patients undergoing minimally invasive cardiac valve surgery. In this retrospective single center study, we aimed to describe the implementation of our ERAS program and to evaluate the results of the first 50 consecutive patients. Our ERAS protocol was developed according to a modified Kern cycle by an expert group, literature search, protocol creation and pilot implementation in the clinical practice. Data of the first 50 consecutive patients undergoing minimally invasive cardiac valve surgery were analysed retrospectively. The key features of our multidisciplinary ERAS protocol are physiotherapeutic prehabilitation, minimally invasive valve surgery techniques, modified cardiopulmonary bypass management, fast-track anaesthesia with on- table extubation and early mobilisation. A total of 50 consecutive patients (mean age of 51.9±11.9 years, mean STS score of 0.6±0.3) underwent minimally-invasive mitral or aortic valve surgery. The adherence to the ERAS protocol was high and neither protocol related complications nor in-hospital mortality occurred. 12% of the patients developed postoperative atrial fibrillation, postoperative delirium emerged in two patients and reintubation was required in one patient. Intensive care unit stay was 14.0±7.4 hours and total hospital stay 6.2±2.9 days. Our ERAS protocol is feasible and safe in minimally-invasive cardiac surgery setting and has a clear potential to improve patients outcome.