Ministernotomy Group Research Articles

Comparison of full and ministernotomy for isolated aortic valve replacement in elderly patients; a prospective randomized study

Aim: To compare the results of isolated aortic valve replacement through ministernotomy and full sternotomy in the elderly.Material and Methods: This single-center prospective study includes patients over 60 years of age who undergone isolated aortic valve replacement either by upper ministernotomy (22 patients) or full sternotomy (22 patients) during 5 years. Both groups were followed 12 months postoperatively.Results: All preoperative and operative measures were similar. However, the ministernotomy group had an average of 3 hours less mechanical ventilation time (p0.001), 200 ml less bleeding (p0.001), 1.5 days shorter hospital stay (p=0.002), and 4 days less analgesic use (p=0.001). Postoperative wound infection (18.2%), sternal detachment (9.1%) and pericardial effusion (4.1%) were seen only in the full sternotomy group.Conclusion: The advantages of ministernotomy are more prominent during recovery period in elderly patients.

EP22 MINIMALLY INVASIVE AORTIC VALVE SURGERY: SINGLE CENTRE EVOLUTION OF TECHNIQUES

Backgrounds: Ministernotomy represents the standard approach to isolated aortic valve replacement (AVR) in our Centre. Sutureless Minithoracotomy AVR has been introduced from 2014. We aim to analize the evolution of techniques in minimally invasive (MI)-AVR. Methods: From November 2014 to January 2018, 216 patients underwent MI-AVR at our Institution: 180 ministernotomy AVR and 36 minithoracotomy Sutureless AVR. Preoperative characteristics showed a higher risk profile in the minithoracotomy group regarding age, hypertension and EUROscore (Table 1). Results: Results are summarized in Table 1. We recorded no mortality in the minithoracotomy, 2/180 (1.1%) in ministernotomy group; two (1.1%) postoperative neurological events in ministernotomy and one (2.8%) in minithoracotomy group (p = 0.67); no paravalvular leak that required redo surgery in both groups. A PM implant was necessary in 8 patients, 4 in ministernotomy (2.2%) and 4 (11.1%) in minithoracotomy group (p = 0.04). Clamping time (CT) and Cardiopulmunary By Pass time (CPB) were lower in minithoracotomy Sutureless AVR group (p CT = 0.01, p CBP = 0.03). Conclusions: MI-AVR can be performed safely, with low postoperative morbidity; sutureless Minithoracotomy AVR widens the minimally invasive portfolio especially in higher risk patients, it is associated with shorter CT and CPB times however it carries a higher risk of PM implant.

Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement

ObjectiveAortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini-sternotomy (MS). The Mini-Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first-time isolated AVR. MethodsThis pragmatic, open-label, parallel randomized controlled trial (RCT) compared MS with FS for first-time isolated AVR in 2 United Kingdom National Health Service hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analyzed in the intent-to-treat population. ResultsIn this RCT, 222 patients were recruited and randomized (n = 118 in the MS group; n = 104 in the FS group). Compared with the FS group, the MS group had a longer hospital length of stay (mean, 9.5 days vs 8.6 days) and took longer to achieve fitness for discharge home (mean, 8.5 days vs 7.5 days). Adjusting for valve type, sex, and surgeon, hazard ratios (HRs) from Cox models did not show a statistically significant effect of MS (relative to FS) on either hospital stay (HR, 0.874; 95% confidence interval [CI], 0.668-1.143; P = .3246) or time to fitness for discharge (HR, 0.907; 95% CI, 0.688-1.197; P value = .4914). During a mean follow-up of 760 days (745 days for the MS group and 777 days for the FS group), 12 patients (10%) in the MS group and 7 patients (7%) in the FS group died (HR, 1.871; 95% CI, 0.723-4.844; P = .1966). Average extra cost for MS was £1714 during the first 12 months after AVR. ConclusionsCompared with FS for AVR, MS did not result in shorter hospital stay, faster recovery, or improved survival and was not cost-effective. The MS approach is not superior to FS for performing AVR.

Role of VATS in thymectomy for non-thymomatous myasthenia gravis

BackgroundThere are different surgical techniques used for thymectomy. Each technique has its own advantages and disadvantages. However, using a less invasive approach would provide a better outcome. MethodsFrom June 2015 to February 2017, a prospective study included a total number of 50 patients of non-thymomatous myasthenia gravis (MG) who were randomly divided into two groups: group A (25 patients who underwent VATS thymectomy), and group B (25 patients who underwent thymectomy via ministernotomy). Efficacy and outcome of both procedures were compared. Patients were followed-up for at least one year postoperatively. ResultsBoth procedures were safe and effective in the management of MG. There was no significant difference between both groups regarding preoperative data. In VATS group, there were significant decreased operative times (p value = 0.00), significant decreased blood loss (p value = 0.039), significant decreased postoperative respiratory and cardiac complications (p value = 0.025 and 0.018 respectively) and significant shorter length of ICU and hospital stays (p value = 0.039 and 0.007 respectively) when compared to ministernotomy group. There was no statistically significant difference between both groups regarding complete stable remissions and clinical improvement. No mortality was recorded in both groups. ConclusionsThoracoscopic thymectomy should be the technique of choice in the management of MG. It has better intraoperative and short-term results than that of thymectomy via ministernotomy. However, longer periods of follow-up is needed to evaluate long-term results properly.

Efficacy of Aortic Valve Replacement through Full Sternotomy and Minimal Invasion (Ministernotomy).

Background: new minimally invasive sternotomy (mini-sternotomy) procedures have improved the treatment outcome and reduced the incidence of perioperative complications leading to improved patient satisfaction and a reduced cost of aortic valve replacement in comparison to the conventional median sternotomy (full sternotomy). The aim of this study is to compare and gain new insights into operative and early postoperative outcomes, long-term postoperative results, and 5-year survival rates after aortic valve replacement through a ministernotomy and full sternotomy. Methods: This is a retrospective study of patients who underwent an isolated replacement of the aortic valve via a full sternotomy or ministernotomy from 2011 to 2016. From 2011 to 2016, 426 cardiac interventions were performed, 70 of which (16.4%) were of the ministernotomy and 356 (83.6%) of the full sternotomy. Through propensity score matching, 70 patients who underwent the ministernotomy (ministernotomy group) were compared with 70 patients who underwent the full sternotomy (control group). Results: in the propensity matching cohort, no statistical difference in operative time was noted (p = 0.856). The ministernotomy had longer cross clamp (88.7 ± 20.7 vs. 80.3 ± 24.6 min, p = 0.007) and bypass (144.0 ± 29.9 vs. 132.9 ± 44.9 min, p = 0.049) times, less ventilation time (9.7 ± 1.7 vs. 11.7 ± 1.4 h, p < 0.001), shorter hospital stay (18.3 ± 1.9 vs. 21.9 ± 1.9 days, p = 0.012), less 24-h chest tube drainage (256.2 ± 28.6 vs. 407.3 ± 40.37 mL, p < 0.001), fewer corrections of coagulopathy (p < 0.001), fewer patients receiving catecholamine (5.71 vs. 30.0%, p < 0.001) and better cosmetic results (p < 0.001). Moreover, the number of patients without complaints at 1 year after the operation was significantly greater in the ministernotomy group (p = 0.002), and no significant differences in the 5-year survival between the groups were observed. In the overall cohort, the ministernotomy had longer cross clamp times (88.7 ± 20.7 vs. 79.9 ± 24.8 min, p < 0.001), longer operative times (263.5 ± 62.0 vs. 246.7 ± 74.2 min, p = 0.037) and bypass times (144.0 ± 29.9 vs. 132.7 ± 44.5 min, p = 0.026), lower incidence of 30-day mortality (1(1.4) vs. 13(3.7), p = 0.022), shorter hospital stays post-surgery p = 0.025, less 24-h chest tube drainage, p < 0.001, and fewer corrections of coagulopathy (p < 0.001). Conclusions: the ministernotomy has a number of advantages compared with the full sternotomy and thus could be a better approach for aortic valve replacement.

Our experience with surgical minimally invasive aortic valve replacement

BackgroundIn the context of the development of modern cardiac valve interventional methods (TAVI, TMVI, MitraClip), miniinvasivity in cardiac surgery is becoming increasingly important. An alternative approach to complete sternotomy in isolated aortic valve replacement (AVR) is access from anterior thoracotomy or upper ministernotomy. In CKTCH Brno, is performed an isolated aortic valve replacement (AVR) from the upper hemisternotomy (UHS) from 2013 onwards. MethodsBetween 2013 and 2016, isolated AVR was perfomed in our institution 666 patients. Full median sternotomy approach was used in 565 patients, minimally invasive approach (UHS) in 101 patients. In the ministernotomy group, classical biological or mechanical prosthesis was implanted in 55 patients; in 46 patients we used rapid deployment (sutureless) bioprosthesis Sorin Perceval S. In our study we compare the results of full sternotomy a hemisternotomy approach and also describe our surgical technique of minimally invasive aortic valve replacement. ResultsWe registered gradual increase in minimally invasive AVR between 2013 and 2016 (9 patients in 2013, 59 patients in 2016). The combined hospitalization and 30-day mortality was 0.53% (3 patients) in the full sternotomy group and 0.99% (1 patient) in the ministernotomy group. In the most risky patients, we indicated ministernotomy with implantation of rapid deployment bioprosthesis (Euroscore II. 3,0 vs. 1,6 in the group of patients with full sternotomy AVR). As published, we confirmed longer aortic cross clamp time (AoX) and lenght of extracorporal circulation (ECC) in the patients with ministernotomy and implantation of sutured aortic prosthesis in comparison with full sternotomy AVR. Conversely, shorter AoX time and ECC time was observed in patients with rapid deployment prosthesis implantation from ministernotomy. We also recorded smaller postoperative blood loss in patients with ministernotomy apporach. The other monitored parameter were comparable. ConclusionIn this study we describe our technique and results of minimally invasive aortic valve replacement in our institution. Based on our results, we evaluate this technique as safe and well reproducible.

Aortos vožtuvo keitimo operacijų naudojant vidurinės sternotomijos ir mini sternotomijos prieigą antsvorio turintiems pacientams rezultatų palyginimas

Darbo tikslasIštirti ir palyginti antsvorio turinčių ligonių pooperacinius rezultatus po aortos vožtuvo keitimo operacijos, naudojant vidurinės sternotomijos ir mini sternotomijos prieigą.Tyrimo medžiaga ir metodaiRetrospektyviai analizuota 112 pacientų, sergančių aortos vožtuvo yda ir turinčių antsvorio (KMI &gt; 25 kg/m2). Jiems 2011–2016 metais aortos vožtuvas pakeistas atliekant mini sternotomiją arba sternotomiją. Naudojant panašiausių atvejų analizės metodą, palygintos dvi grupės: 56 pacientų, kuriems atlikta mini sternotomija, ir 56 pacientų, kuriems operacija atlikta per vidurinės sternotomijos prieigą (kontrolinė grupė).RezultataiNaudojant mini sternotomijos prieigą, operacijos trukmė buvo patikimai ilgesnė – 264 ± 62 min., palyginti su 246 ± 72 min. (p = 0,046) kontrolinėje grupėje, buvo ilgesnis aortos užspaudimo laikas – atitinkamai 91 ± 20 min. ir 76 ± 23 min. (p &lt; 0,001), bei dirbtinės kraujo apykaitos trukmė – atitinkamai 148 ± 4 min. ir 133 ± 2,7 min. (p = 0,023). Mini sternotomijos grupėje rečiau pasitaikė pooperacinis ūminis inkstų nepakankamumas – 2 (3,6 %), palyginti su 12 (21,43 %) kontrolinėje grupėje (p = 0,004). Mini sternotomijos grupėje buvo trumpesnis hospitalizacijos, gydymo intensyviosios terapijos skyriuje, plaučių ventiliacijos laikas, mažesnis pooperacinis kraujo netekimas. Tačiau skirtumai buvo statistiškai nereikšmingi.IšvadosAntsvorio turintiems pacientams mini sternotomija yra saugus metodas, leidžiantis atlikti sudėtingas chirurgines aortos vožtuvo intervencijas. Kadangi rezultatai nenusileidžia vidurinės sternotomijos rezultatams, o kartais jie yra net geresni, rekomenduojame šią prieigą kaip saugią ir mažiau traumuojančią aortos vožtuvo keitimo alternatyvą antsvorio turintiems pacientams.

Mejora de la morbilidad postoperatoria en recambio valvular aórtico aislado con miniesternotomía: estudio pareado por puntuación de propensión

BackgroundMinimally invasive aortic valve surgery using the upper mini-sternotomy is becoming more popular in our ¿country?, due to its advantages over conventional median sternotomy. An analysis is presented on the outcomes in our centre for the two years after the implementation of the technique in November 2013. MethodsAn observational analytical retrospective study was conducted on 92 consecutive patients who underwent isolated aortic valve replacement due to severe aortic stenosis after November 2013. Propensity score matching with “nearest neighbour matching” protocol was performed to obtain two groups of 40 patients (mini-sternotomy group and conventional group) for comparison (Primary combined end-point of 6 major adverse cardiac and cerebrovascular events, and secondary end-points such as cardiopulmonary bypass and cross-clamp times, intubation time, bleeding in first 24hours, transfusions, and survival). ResultsMedian cardiopulmonary bypass and cross-clamp times were 15 and 10minutes longer in the mini-sternotomy group (89 [75–110] and 74 [64–90] versus conventional group 65 [55–73] and 55 [47–63] minutes, respectively, P<.001). The mini-sternotomy group had less major complications events (12.5% versus 30% conventional group, p=.05, Odds Ratio 0.32; 95% Confidence Interval; 0.09 -0.93), bleeding in 24hours (304±150ml vs. 506±300ml conventional, p<.001) and transfusion requirements (0.8±0.2 vs. 1.6±0.3 packed red blood cells per patient p=.04). No differences were found in intubation time, hospital stay, mortality, or survival. ConclusionsIsolated aortic valve replacement using mini-sternotomy shows a reduction in morbidity and mortality, so we recommend its use instead of conventional surgery, whenever possible. Further clinical trials are needed to confirm these data.

Non-sutureless minimally invasive aortic valve replacement: mini-sternotomy versus mini-thoracotomy: a series of 1130 patients.

Aortic valve replacement through conventional sternotomy still represents the gold-standard surgical approach for aortic valve disease. However, given the increasing number of patients with comorbidities, strategies that can improve operative results are always sought. Minimally invasive aortic valve surgery, although related to a steep learning curve, might be associated with improved postoperative outcomes. The main aim of this study was to assess whether significant differences exist in terms of operative and early results between a mini-sternotomy and a right mini-thoracotomy approach for isolated aortic valve replacement without sutureless technologies. This is an observational retrospective multicentre study from nine Italian cardiac centres that analyses prospectively collected data of patients who underwent isolated minimally invasive aortic valve replacement between January 2010 and December 2014. Two approaches are considered (mini-sternotomy and mini-thoracotomy) and compared in terms of operative and early outcomes. After interrogation of the centralized database, a total of 1130 patients were retrieved (854 mini-sternotomy and 276 mini-thoracotomy). Patients in the mini-sternotomy group had a higher risk profile. There was no difference in terms of early mortality; cardiopulmonary bypass and cross-clamp time did not differ significantly between the groups; and a significantly higher number of reoperations for bleeding was observed in the right mini-thoracotomy group. Both mini-sternotomy and mini-thoracotomy could be performed safely, with low mortality and postoperative morbidity. The mini-thoracotomy approach was associated with a significantly higher rate of reoperation for bleeding. Uptake among cardiac centres was low. Sutureless technologies could potentially increase surgical volume by simplifying the mini-thoracotomy procedure.

A comparative study between L shaped ministernotomy and conventional mitral valve surgery

ObjectiveIt is to determine whether minimally invasive mitral and tricuspid valve surgery through lower ministernotomy improved postoperative outcome when compared to the conventional surgery through total sternotomy. The comparison included: intraoperative time parameters, postoperative complications, intensive care unit and hospital stays, postoperative echocardiography, and in-hospital mortality rate. Patients and methodsBetween September 2013 and August 2015 a total number of 41 patients, who underwent mitral and tricuspid valve operations (mitral valve replacement with or without tricuspid valve repair) in Cairo University as well as one of the ministry of health hospitals were included in this study. Of these patients: 19 cases were operated upon via inverted L shaped partial lower sternotomy (Group I) and 22 cases received conventional sternotomy (Group II). ResultsThere was no statistically significant difference between the two groups in terms of cross clamp time, cardiopulmonary bypass time; however the total procedure time was in favor of the conventional approach. There was a statistically significant difference between the two groups regarding the amount of chest tube drainage, and the need for blood transfusion which was lower in the ministernotomy group. There was a statistically significant difference between the two groups in the ventilation time in favor of the ministernotomy group. The study showed no statistically significant difference in mortality rate between the two groups. ConclusionMinisternotomy approach for mitral and tricuspid valve surgery is a safe and feasible technique. This technique provides many advantages such as smaller incision with traditional exposure and familiar instruments, decreased amount of postoperative bleeding, need for blood transfusion and decreased duration of ventilation time.

Lower mini-sternotomy in congenital heart disease: just a cosmetic improvement?

Lower mini-sternotomy represents a minimally invasive surgical technique that has been utilized for the repair of a wide variety of congenital heart defects with excellent surgical and cosmetic outcomes. However, clinical improvements provided for this technique beyond cosmetic results are controversial. The aim of our study is to report our results with lower mini-sternotomy for the repair of congenital heart malformations and compare them with a matched group with a full median sternotomy approach. From 2010 through 2013, 105 consecutive congenital patients (81 paediatric) underwent lower mini-sternotomy at our centre (Group 1). We analysed in-hospital and follow-up outcomes, and compare them with an age-sex-diagnosis-type of surgery-matched group (Group 2). Both groups were managed following the same clinical protocols. In Group 1, age at the time of surgery was 12 ± 17 years (range from 0.2 to 64.6 years). In this group, 81 patients were paediatric and 62 were female. Operative techniques were atrial septal defect (n = 72), ventricular septal defect (n = 24) and atrioventricular canal repairs (n = 9). There were no deaths or major in-hospital complications. Two adult patients required conversion to full median sternotomy. For a medium follow-up of 1.5 years (range from 1 month to 5 years), there were no deaths, reinterventions or reoperations and no significant residual defects were found. Compared with Group 2, patients in Group 1 had longer cardiopulmonary bypass times (58.71 ± 19.08 vs 45.39 ± 20.45, P < 0.001) and cross-clamp times (32.75 ± 13.11 vs 23.22 ± 13.93, P < 0.001), higher rate of early extubation (96 vs 85%, P = 0.018) and lower rate of postoperative complications (11.6 vs 22.3%, P = 0.034). At our centre, lower mini-sternotomy represents a safe alternative for the repair of congenital heart defects in paediatric and adult populations. Cardiopulmonary bypass and cross-clamp times were longer in the mini-sternotomy group. However, these patients showed earlier extubation and less postoperative complications when compared with patients with a full sternotomy approach. Combined with improved cosmetic outcomes, lower mini-sternotomy could represent the technique of choice for these populations.

Ministernotomy Versus Full Sternotomy Aortic Valve Replacement With a Sutureless Bioprosthesis: A Multicenter Study

The aim of this study was to analyze early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) with the sutureless Perceval bioprosthesis (Sorin Biomedica Cardio Srl, Salluggia, Italy) performed through ministernotomy compared with full sternotomy. This was a study of 267 consecutive patients who underwent isolated AVR with the sutureless Perceval bioprosthesis between 2007 and 2014 at 6 European centers. Of these, 189 (70.8%) were performed through ministernotomy and 78 through a full sternotomy. Propensity score matching was used to reduce selection bias. In the overall cohort of ministernotomy and full sternotomy patients, in-hospital mortality was 1.1% and 2.6% and 2-year survival was 92% and 91%, respectively. Propensity score matching resulted in 56 pairs with similar characteristics and operative risk. Aortic cross-clamp (44 minutes in both groups, p = 0.931) and cardiopulmonary bypass time (69 vs 74 minutes, p = 0.363) did not differ between the groups. Apart from higher values in the ministernotomy group for postoperative peak gradients (28.1 vs 23.3 mm Hg, p = 0.026) and mean aortic valve gradients (15.2 vs 11.7 mm Hg, p = 0.011), early postoperative outcomes did not differ in the propensity-matched cohort. There were no differences in the in-hospital mortality rate or 2-year survival between the groups. AVR with the sutureless Perceval bioprosthesis through a ministernotomy was a safe and reproducible procedure that was not associated with prolonged aortic cross-clamp or cardiopulmonary bypass time compared with a full sternotomy. Early postoperative outcomes and 2-year survival were comparable between patients undergoing ministernotomy and full sternotomy.

The Efficacy and Outcome of Ministernotomy Compared to Those of Standard Sternotomy for Aortic Valve Replacement

Background. Benefits of ministernotomy have been reported but not yet fully established in the current literature. Ministernotomy may be associated with less bleeding, less need for transfusion, and reduced hospital length of stay. Methods. We retrospectively evaluated 347 patients who underwent aortic valve replacement between 2007 and 2011 at our institution. Results. Standard sternotomy was performed in 303 patients (154 males, 50.8% and 149 females, 49.2%) and ministernotomy in 44 patients (13 males, 30% and 30 females, 70%); most of the patients in ministernotomy group were female (75%) (P=.0095). The mean age for ministernotomy patients was 71.8±12.6 years and for sternotomy patients 67.4±13.8 years (P=.045). Significant preoperative morbidities (for ministernotomy and sternotomy, resp.) included stroke (11%, n=5 versus 18%, n=55; P=.39), PVD (23%, n=10 versus 16%, n=49; P=.29), COPD (25%, n=11 versus 17%, n=52; P=.21), renal failure (0.0%, n=0 versus 8.8%, n=26; P=.06), and previous heart surgery (9%, n=4 versus 9.5%, n=29; P=1.0). Intraoperative blood transfusion was required in 23% of ministernotomy patients (n=9) and 30% of sternotomy patients (n=91), P=.16. Major postoperative complications (for ministernotomy and sternotomy, resp.) included exploration for bleeding (4.5%, n=2 versus 6%, n=18; P=1) and adverse neurologic events (4.5%, n=2 versus 1.6%, n=5; P=.05). The length of stay (LOS) in the CCU was 75.4±57.1 hours for the ministernotomy group and 125.4±160.3 hours for the sternotomy group (P=.12). The LOS was slightly shorter following ministernotomy (9.00±7.78 days) compared to sternotomy (10.0±9.46 days) (P=.31). Perioperative mortality was 2.3% (n=1) for ministernotomy and 3.3% (n=10) for sternotomy (P=1.0). The 1-, 3-, and 7-year survival following ministernotomy was 93.8%, 93.8%, and 88.3%, respectively; following sternotomy, these rates were 87.7%, 83.7%, and 82.6%, respectively (95% CI 0.273 to 1.325, P=.20). Conclusion. Ministernotomy is less invasive and is associated with less perioperative and postoperative bleeding and reduced LOS in CCU and in hospital.

Minimally invasive aortic valve replacement using right minithoracotomy is associated with better outcomes than ministernotomy

To compare the outcomes of right minithoracotomy (RT) versus ministernotomy (MS) in patients undergoing minimally invasive aortic valve replacement (AVR). From January 2005 to December 2011, 406 patients underwent minimally invasive AVR, of whom 251 patients were in the RT group and 155 were in the MS group. The overall in-hospital mortality was 1.2% with no difference between the 2 groups (1.2% in RT vs 1.3% in MS). Patients undergoing minimally invasive AVR using RT had a lower incidence of postoperative atrial fibrillation (19.5% vs 34.2%, P=.01), shorter ventilation time (median, 7 vs 8 hours; interquartile range, 5-9 vs 6-12 hours, P=.003), intensive care unit stay (median 1 vs 1 day; interquartile range, 1-1 vs 1-2 days; P=.001), and hospital stay (median, 5 vs 6 days; interquartile range, 5-6 vs 5-8 days; P=.0001). No difference was found in terms of cardiopulmonary time, crossclamping time, postoperative stroke, re-exploration for bleeding, or blood transfusion. Minimally invasive AVR using RT was associated with lower postoperative morbidities and a shorter hospital stay than MS.

Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of randomised controlled trials

BackgroundMini-sternotomy for isolated aortic valve replacement aims to reduce operative trauma hastening recovery and improving the cosmetic outcome of cardiac surgery. The short-term clinical benefits from the mini-sternotomy are presumed...

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There are different surgical techniques used for thymectomy. Each technique has its own advantages and disadvantages. However, using a less invasive approach would provide a better outcome.From June 2015 to February 2017, a prospective study included a total number of 50 patients of non-thymomatous myasthenia gravis (MG) who were randomly divided into two groups: group A (25 patients who underwent VATS thymectomy), and group B (25 patients who underwent thymectomy via ministernotomy). Efficacy and outcome of both procedures were compared. Patients were followed-up for at least one year postoperatively.Both procedures were safe and effective in the management of MG. There was no significant difference between both groups regarding preoperative data. In VATS group, there were significant decreased operative times (p value = 0.00), significant decreased blood loss (p value = 0.039), significant decreased postoperative respiratory and cardiac complications (p value = 0.025 and 0.018 respectively) and significant shorter length of ICU and hospital stays (p value = 0.039 and 0.007 respectively) when compared to ministernotomy group. There was no statistically significant difference between both groups regarding complete stable remissions and clinical improvement. No mortality was recorded in both groups.Thoracoscopic thymectomy should be the technique of choice in the management of MG. It has better intraoperative and short-term results than that of thymectomy via ministernotomy. However, longer periods of follow-up is needed to evaluate long-term results properly.

Ministernotomy versus complete sternotomy for coronary bypass operations: No difference in postoperative pulmonary function

Objectives: Less-invasive approaches in cardiac operations offer certain cosmetic advantages, but it is unclear whether there are additional positive effects with regard to the postoperative recovery of patients. The aim of this prospective and randomized study was to ascertain whether partial inferior midline sternotomy can improve pulmonary function, one of the best quantifiable parameters of postoperative recovery, after coronary artery bypass operations when compared with the standard full midline approach. Methods: One hundred patients scheduled for elective coronary artery bypass grafting were randomized either for a full median sternotomy (standard sternotomy group, n = 50) or for a partial inferior sternotomy (ministernotomy group, n = 50). The following pulmonary features were assessed: vital capacity, forced expiratory volume, percentage of forced expiratory volume from vital capacity, total lung capacity, residual volume, maximum inspiratory pressure, and maximum expiratory pressure. Tests were performed preoperatively and on the fourth and tenth postoperative days. Results: On the fourth postoperative day, both groups had a significant decrease in vital capacity (percentage of predicted values) when compared with preoperative values (preoperative vs fourth day: standard sternotomy group, 87.8% ± 14.3% vs 42.1% ± 10.2% [P <.0001]; ministernotomy group, 84.5% ± 14.3% vs 41.5% ± 11.8% [P <.0001]), with a significant tendency for recovery from the fourth to the tenth postoperative day (fourth vs tenth postoperative day: standard sternotomy group, 42.1% ± 10.2% vs 66.3% ± 12.3% [P =.001]; ministernotomy group, 41.5% ± 11.8% vs 61.3% ± 13.1 % [P =.002]). There were no differences in any test results between the groups on either the fourth or the tenth postoperative day. Conclusion: A less-invasive approach for coronary artery bypass operations with a partial inferior sternotomy does not improve early postoperative pulmonary function when compared with the conventional approach with a full sternotomy. (J Thorac Cardiovasc Surg 2001;121:702-7)

Ministernotomy versus full sternotomy in congenital heart defects: a prospective randomized study

Background. Although the ministernotomy is extensively used in the repair of congenital heart defects all over the world, whether this approach has additional advantages over the conventional full sternotomy is not well established. This prospective study was designed to evaluate the effects of lower ministernotomy in the repair of congenital heart defects. Methods. One hundred patients who underwent repair of atrial or ventricular septal defects were randomly divided into two groups: lower ministernotomy group (n = 50), and full sternotomy group (n = 50). The clinical indexes of each procedure were recorded and analyzed. Results. The age, sex, and types of cardiac defects were comparable between the two groups. Ischemic times, bypass times, intensive care unit stay, and ventilation duration were similar in both groups. The procedure time (from skin to skin) was longer in the lower ministernotomy group than in the full sternotomy group ( p < 0.001). There was less drainage in the lower ministernotomy group than in the full sternotomy group for the first 24 hours after operation (186 ± 99 mL/m 2 versus 237 ± 134 mL/m 2, p = 0.03) but no significant difference in transfusions between the two groups. The hospital stay was shorter in the lower ministernotomy group than in the full sternotomy group (6.5 ± 1.2 days versus 7.5 ± 1.8 days, p = 0.02). Conclusions. Ministernotomy is as safe and effective as a full sternotomy in the repair of simple congenital heart defects in older children and adults. Furthermore, this small incision reduces the postoperative drainage, shortens hospital stay, and provides better cosmetic results. Operative times are longer.

Minimal access approach for the repair of atrial septal defect: the initial 135 patients

Background. From May 1996 to August 1998 a minimal access approach was used for 135 of 200 consecutive surgical atrial septal defects closures in children through young adults ranging in age from 6 months to 25 years (median 5 years). Methods. A 3.5- to 5-cm midline incision was centered over the xiphoid with division of the xiphoid alone (transxiphoid) or of the lower sternum (ministernotomy); both groups underwent bicaval venous cannulation through the incision. Cardioplegia and aortic cross-clamping were administered through the incision. Cephalad retraction of the sternum with a fixed-arm retractor aided exposure. Results. There have been no early or late deaths and no bleeding or wound complications. No procedure required conversion to a full sternotomy, and no cannulation attempt was abandoned for an alternate site. Cross-clamp and cardiopulmonary bypass times were equivalent to those in the full sternotomy group. The mean length of hospital stay in the ministernotomy group was 2.7 days. Conclusions. The closure of atrial septal defects can be performed through a transxiphoid or ministernotomy approach, conferring a satisfactory cosmetic result without compromising the safety or accuracy of the repair.

“I” ministernotomy for aortic valve replacement

Background. Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement.Methods. Eighteen patients were operated on by means of an “I” ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was no difference between these two groups in term of age, sex, and preoperative left ventricular ejection fraction. In patients of the ministernotomy group, the operations were approached through an “I” median sternal split, from the second to the fifth intercostal space, 8 to 10 cm in length, with transverse division. Cardiopulmonary bypass was established through aorto–right atrial cannulation with aortic cross-clamping and antegrade or retrograde delivery of blood cardioplegia.Results. Under direct vision, aortic valve replacement was performed successfully in patients of both groups. The duration of cardiopulmonary bypass time and aortic cross-clamp time was significantly longer in the ministernotomy group than in the full sternotomy group. However, the length of incision, duration of endotracheal intubation, intensive care unit stay, pain score, postoperative length of stay, and return to normal activity interval were significantly shorter and lower in patients of the ministernotomy group than in those of the full sternotomy group. All patients recovered from the operation rapidly. Follow-up was complete in all patients with no late complications. Echocardiographic examination showed good function of aortic prostheses.Conclusions. Our experience demonstrates that the “I” ministernotomy provides good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.