Right Anterior Minithoracotomy Research Articles

Right anterior minithoracotomy with preservation of the vascular bundle for correction of congenital ventricular septal defects

Introduction Congenital VSDs require early correction to avoid serious complications. For many years, the gold standard was the median longitudinal sternotomy, but given the gross cosmetic effect, miniapproaches were developed, but right anterior mini-thoracotomies gained popularity. We modified the method of anterior right-sided minithorcatomy by preserving a. et v. mammaria interna and the purpose of the study was to evaluate its effectiveness.
 Material and Methods The design of the study was prospective with historical control. A total of 82 patients who underwent VSD correction were included in the study. All patients were divided into three groups: group 1 operated by median sternotomy (MS) – 15 patients; Group 2 operated by right anterior minithoracotomy (RAMT) – 38 patients; and the 3rd main group operated on by right antero-lateral thoracotomy (RLMT) with preservation of the artery and vein of the internal mammary artery - 29 patients.
 Results We revealed the older age in RAMT group. Cardio pulmonary bypasstime and total operation time were shorter in RLMT group, but the time of aortic cross-clamping is shorter than in RAMT group, but longer than in MS group. The length of the skin incision is also the shortest in RLMT group, which enhances the cosmetic effect. Also there were revealed a shorter mechanical lung ventilation time and ICU stay, moreover we observed reduced amount of drainages, as well as quick discharge home.
 Conclusion Therefore, improved and modificated right antero-lateral minithoracotomy method with preserving a et v mammaria interna is feasible, has a good cosmetic effect, and short hospitalization stay, but should perform with careful preparation of the entire cardiac team.
 Bangladesh Journal of Medical Science Vol. 23 No. 02 April’24 Page : 514-520

Sternalsparing aortic valve replacement via right anterior minithoracotomy: An early experience.

This study aims to evaluate the perioperative outcomes of aortic valve replacement (AVR) via right anterior minithoracotomy (RAT) during the learning curve. It was a retrospective, observational, cohort study of patients who underwent RAT AVR from June 2015 to April 2022. Primary outcomes measured were 30-day morbidity and mortality. A total of 107 consecutive patients underwent elective RAT AVR. Our patients were mostly male (78.5%), elderly (mean 68.7 years), and obese (34.6%). A majority of the patients (93.5%) were of low operative risk. Median cross-clamp and bypass times were 95 and 123 minutes respectively. There was a statistically significant correlation between increase in number of cases and decrease in operative time. All patients had no paravalvular leak at discharge. There were no operative cardiovascular mortality or major morbidity including stroke, myocardial infarction, renal failure requiring dialysis, or vascular complication. No patient required intraoperative conversion to full sternotomy for completion of AVR. Our study demonstrated that RAT AVR can be safely introduced. The learning curve required in performing RAT AVR can be safely negotiated through training, previous experience in minimally invasive surgery, careful patient selection including use of preoperative computed tomography of the aorta, and introduction of sutureless/rapid deployment valves.

Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy Versus Conventional Sternotomy: A Propensity Matched Retrospective Cohort Analysis of Short-Term Outcomes

Aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is purported to offer the benefits of surgical valve replacement without the morbidity of median sternotomy. This is the largest cohort of patients who underwent AVR via RAMT reported in Australia. The availability of transcatheter approaches has made treatment decisions for patients with aortic stenosis more complex. Reporting of current Australian data is key to informed decision-making for patients and clinicians. This study aimed to compare the perioperative outcomes of AVR via the RAMT approach versus conventional full sternotomy.

Surgery of the ascending aorta via a right anterior minithoracotomy: initial surgical experience of a single center

Objectives Full median sternotomy (FMS) is the common surgical access for patients undergoing replacement of the ascending aorta (AA) with or without aortic valve replacement (AVR). The right anterior mini-thoracotomy (RAMT) approach has been increasingly adopted for AVR. This approach has been shown to decrease blood loss and hospital length of stay (LOS) compared with FMS. The RAMT approach may also be beneficial in selected patients requiring AA procedures with or without AVR. We present our initial clinical experience of patients who have undergone a RAMT for supracommissural replacement of the tubular AA with or without AVR. Methods This is a single-center retrospective review of 10 patients who underwent an elective RAMT for replacement of the tubular AA with or without AVR between November 2019 and January 2022. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital LOS, time to extubation, operative times, as well as postoperative complications such as stroke and bleeding. Results Median cross-clamp and cardiopulmonary bypass times were 109 and 148 min, respectively. Median time to extubation was 2.5 h and median intensive care unit and hospital stay were 2 and 10 days, respectively. There were two re-thoracotomies for postoperative bleeding and two cases of sub-xiphoidal pericardial drainage for pericardial effusion. There were no strokes and no in-hospital nor 30-day mortalities. Conclusions The replacement of the AA with or without concomitant AVR can be performed through a RAMT in carefully selected patients. However, the safety of this approach, as compared to full/partial median sternotomy, remains to be proven.

A Decision-Support Informatics Platform for Minimally Invasive Aortic Valve Replacement

Minimally invasive aortic valve replacement is performed by mini-sternotomy (MS) or less invasive right anterior mini-thoracotomy (RT). The possibility of adopting RT is assessed by anatomical criteria derived from manual 2D image analysis. We developed a semi-automatic tool (RT-PLAN) to assess the criteria of RT, extract other parameters of surgical interest and generate a view of the anatomical region in a 3D space. Twenty-five 3D CT images from a dataset were retrospectively evaluated. The methodology starts with segmentation to reconstruct 3D surface models of the aorta and anterior rib cage. Secondly, the RT criteria and geometric information from these models are automatically and quantitatively evaluated. A comparison is made between the values of the parameters measured by the standard manual 2D procedure and our tool. The RT-PLAN procedure was feasible in all cases. Strong agreement was found between RT-PLAN and the standard manual 2D procedure. There was no difference between the RT-PLAN and the standard procedure when selecting patients for the RT technique. The tool developed is able to effectively perform the assessment of the RT criteria, with the addition of a realistic visualisation of the surgical field through virtual reality technology.

Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center.

The goal of this manuscript was to report the clinical outcomes of the initial series of 100 consecutive Right Anterior Mini Thoracotomy (RAMT) aortic valve replacement (AVR) implantations at a Canadian Center. This retrospective study reported the clinical outcomes of the first 100 patients who underwent the RAMT approach for isolated surgical AVR in Calgary, Canada, between 2016 and 2020. Primary outcomes were death within 30 days of surgery and disabling stroke. Secondary outcomes included surgical times, the need for permanent pacemaker (PPM), incidence of postoperative blood transfusion in the intensive care unit (ICU), postsurgical atrial fibrillation (AF), length of ICU/hospital stay, postsurgical AF, residual paravalvular leak (PVL), postoperative transvalvular gradient, need for postsurgical intravenous opioids, duration of invasive ventilation in the ICU, and chest tube output in the first 12 h postsurgery. In this study, 54 patients were male, and the average age of the cohort was 72 years. Mortality within 30 days of surgery was 1% with no disabling postoperative strokes. Mean cardiopulmonary bypass and cross clamp was 84 and 55 min, respectively. PPM rate was 3%, incidence of blood transfusion in the ICU was 4%, and the rate of postoperative AF was 23%. Median length of ICU and hospital stay was 1 and 5 days, respectively. Rate of mild or greater residual PVL was 3%, while the average residual transvalvular mean gradient was 8.5 mmHg. The sternum-sparing RAMT approach can be safely integrated into surgical practice as a minimally invasive alternative for isolated AVR, and can reduce postoperative bleeding and narcotic requirements.

The First 100 Cases of Two Innovations Combined: Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Mini-Thoracotomy Using a Novel Aortic Prosthesis.

IntroductionAortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is less traumatic than via other surgical routes; using a novel aortic valve may confer long-term resistance against valve deterioration, and thus be useful in younger, more active patients. Here we aim to validate using the INSPIRIS RESILIA valve with minimally invasive RAMT. MethodsBetween April 2017 and June 2019, 100 patients underwent video-assisted minimally invasive AVR by RAMT, using the INSPIRIS RESILIA aortic valve. Cannulation for cardiopulmonary bypass (CPB) was through femoral vessels. Clinical data were prospectively entered into our institutional database.ResultsCardiopulmonary bypass (CPB) and cross-clamping times were 79 ± 38 and 41 ± 17 min. Surgical access was successful in 100% of cases. There were no cases of intraoperative mortality, 30-day mortality, cerebrovascular events, rethoracotomy for bleeding, valve-related reoperation, right internal mammary artery injury, or conversion to sternotomy. Intensive care and hospital stays were 2 ± 1 and 6 ± 3 days, respectively. One patient had a pacemaker fitted. Postoperative dialysis was necessary in one patient. Trace to mild aortic valve regurgitation occurred in two patients. No structural valve deterioration (SVD) and paravalvular leak were seen. At 1-year follow-up mean effective orifice area (EOA) was 1.8 ± 0.1 cm2, peak gradient was 22.1 ± 3.1 mmHg, and mean gradient was 11.5 ± 2.3 mmHg.ConclusionOur preliminary experience suggests that RAMT for AVR using the INSPIRIS RESILIA aortic valve is safe, effective, and reproducible. Larger studies are needed to evaluate the long-term efficacy and durability of this new valve.

Comparison of sutured valves and suturless and rapid deployment valves in aortic valve surgery by minimally invasive approach

During the development of aortic valve replacement (AVR) by minimally invasive approach, the use of suturless (Perceval) and rapid deployment valves (Intuity and Intuity Elite) grew in popularity due to they are surgical time-saving. Our aim was to evaluated the efficacy and safety of these type of valve compared to conventional sutured valve in isolated AVR by right anterior minithoracotomy (RAMT). Between September 2009 and March 2020, 546 patients underwent isolated AVR by RAMT. Patient data were collected prospectively. Statistical analysis was performed to compare the use of suturless and rapid deployment valve (SRDV) and conventional sutured valve (CV). Of the 546 patients, 398 underwent AVR using CV (72,9%) and 148 using a SDRV (27,1%). The aortic cross-clamping and cardiopulmonary bypass times were significantly decreased in SRDV group (66,6 ± 27 vs 88,5 ± 27,6 min; P < 0,001 and 95 ± 39,7 vs. 119 ± 41 min; P < 0,001). The rate of permanent pacemaker implantation was significantly higher in SRDV group (10,9 vs 1,05%; P < 0,001). Pacemaker implantation was predominant with using Perceval valve compared to Intuity valve (12,6 vs. 3,6%). The lengths of ICU and hospital stay were significantly decreased in group CV (2,5 ± 2,4 vs. 3,1 ± 3,7 days; P = 0,03 and 8,1 ± 5 vs. 8.9 ± 4.6 days; p = 0,001). The mortality rate was significantly higher (4,7 vs. 1,2%; P = 0,01) in group SRDV but the mean age and Euroscore II were significantly higher in SRDV group (76,1 + - 6,2 vs. 68,5 ± 9,8 years; P < 0.001 and 2,1 ± 1,9 vs. 1,6 ± 2,1; P < 0.001). The use of SDRV in minimally invasive aortic valve surgery reduces the duration of myocardial ischemia, but at the cost of a significant increase in rate of permanent pacemaker implantation. Their use is also associated with a significant increase in the length of stay in intensive care unit and hospital.

Right anterior mini-thoracotomy and sutureless valves: the perfect marriage.

A minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates a MIA. We describe our experience with the sutureless Perceval (LivaNova, Italy) aortic bioprosthesis through a right anterior mini-thoracotomy (RAMT) approach. Between March 2011 and October 2019, 1,049 patients underwent AVR with Perceval bioprosthesis. Five hundred and three patients (48%) were operated through a RAMT approach in the second intercostal space. Considering only isolated AVR (881), 98% of patients were operated with MIA, and Perceval in RAMT approach was performed in 57% of these patients. Eight patients (1.6%) had previously undergone cardiac surgery. The prosthesis sizes implanted were: S (n=91), M (n=154), L (n=218) and XL (n=40). Concomitant procedures were mitral valve surgery (n=6), tricuspid valve repair (n=1), mitral valve repair and tricuspid valve repair (n=1) and miectomy (n=2). Mean age was 78±4 years (range, 65-89 years), 317 patients were female (63%) and EuroSCORE II was 5.9%±8.4%. The 30-day mortality was 0.8% (4/503). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were 81.6±30.8 and 50.3±24.5 minutes respectively for stand-alone procedures. In two patients, early moderate paravalvular leakage appeared as a result of incomplete expansion of the sutureless valve due to oversizing of the bioprosthesis, requiring reoperations at two and nine postoperative days with sutured aortic bioprosthesis implantation. Permanent pacemaker implantation within the first thirty days was necessary in 26 (5.2%) patients. At the mean follow-up of 4.6 years (range, 1 month to 8.6 years), survival was 96%, freedom from reoperation was 99.2%, and mean transvalvular pressure gradient was 11.9±4.3 mmHg. AVR with the Perceval bioprosthesis in a RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates a RAMT approach.

Multiple Valve Implantation Through a Minimally Invasive Approach: Comparison of Standard Median Sternotomy and Right Anterior Thoracotomy

Following developments in the area of minimally invasive surgery and good, recently published surgical results, the areas in which minimally invasive surgery can be used are beginning to expand. This study aimed to describe experience and show the feasibility and safety of minimally invasive multiple valve implantation with right anterior minithoracotomy (RAT) and compare the outcomes with cases that underwent multiple valve surgery via a standard median sternotomy. The study cohort comprised 52 patients with combined valvular disease who underwent aortic valve replacement and mitral valve replacement or repair, and/or tricuspid valve ring annuloplasty through median sternotomy (control group n=32) or minimally invasive surgery through a RAT (study group n=20) between January 2012 and December 2018 at the current centre. Preoperative evaluation included coronary catheterisation and multisliced computerised tomography in all patients. Postoperative clinical outcomes and haemodynamic performance of heart valves were reviewed. The mean age of patients was 72.6±7.1 years, and 50% were male. Seventeen (17) patients (32.6%) were in New York Heart Association functional class III or IV. Three (3) patients (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 21±3.9 months (maximum 26 months). No major paravalvular leakage occurred, and there was no postoperative valve migration in either group. Non-valve-related deaths occurred in five patients during follow-up. This study showed that minimally invasive multiple valve implantation is a technically feasible and safe procedure with acceptable surgical outcomes and similar postoperative quality when compared with median sternotomy.

RF07 AORTIC VALVE REPLACEMENT WITH SUTURELESS PERCEVAL BIOPROSTHESIS IN RIGHT ANTERIOR MINITHORACOTOMY APPROACH: SINGLE CENTER EXPERIENCE WITH 461 IMPLANTS

Abstract Background and Aim: Minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates MIA. We describe our experience with sutureless Perceval (LivaNova, Italy) aortic bioprosthesis in right anterior minithoracotomy (RAMT) approach. Methods: Between March 2011 and December 2017, 841 patients underwent AVR with Perceval bioprosthesis. 461 patients were operated through RAMT approach. Considering only isolated AVR (530), Perceval in RAMT approach was performed in 87% of patients. Prosthesis sizes implanted were: S (n = 67), M (n = 147), L (n = 218) and XL (n = 29). Concomitant procedures were mitral valve surgery (n = 5), tricuspid valve repair (n = 1), mitral valve repair and tricuspid valve repair (n = 1), and miectomy (n = 2). Mean age was 77.2 ± 6.5, 61.12 % patients were female, and mean logistic EuroSCORE was 12.7 ± 9.9. Results: The 30-day mortality was 0.65% (3/461). Cardiopulmonary bypass and aortic cross-clamp times were 82.3 ± 30.8 and 52 ± 21.6 minutes for stand-alone procedures. In 3 patients appeared early moderate paravalvular leakage required reoperations. Permanent pacemaker implantation within the first 30 days was necessary in 5% of patients. At mean follow-up of 28.6 ± 12.4 months, survival was 97%, freedom from reoperation was 98%, and mean transvalvular pressure gradient was 11.7 ± 5 mmHg. Conclusions: AVR with Perceval bioprosthesis in RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates RAMT approach.

RF89 TWENTY-YEAR OF MINIMALLY INVASIVE SURGERY FOR ATRIAL SEPTAL DEFECTS: TECHNICAL EVOLUTION AND RESULTS

Background: We evaluate the results of our 20-year experience with minimally invasive surgical approaches (MISA) for closing ostium secundum atrial septal defects (ASD II), focusing on technical evolution and efficacy. Methods: We included 538 patients who underwent surgical ASD II closure by using MISA. Results: MISA included: right-anterior mini-thoracotomy (RAMT)(n = 335, 62%), mid-line mini-sternotomy (MS) (135, 25%) and right-lateral mini-thoracotomy (RLMT) (n = 68, 13%). Central cannulation was employed in 374 patients (69%), while a remote cardiopulmonary bypass with peripheral cannulation in the remaining 164 patients (30%). Five patients (0.9%) had major postoperative complications requiring further surgical intervention. All patients were discharged in good clinical conditions, without any significant residual intra-cardiac defect. A decrease of the length of hospitalization (p &lt; 0.001) and hospital costs (p = 0.009) was demonstrated by year of surgery. At a median follow-up of 12.1 years (IQR 0.6–14 years), all patients are in good clinical conditions with no limitation to physical activity. The overall satisfaction rate for the cosmetic result of MISA was 97% (524/538 patients)(99% in the last 5 years, 99/100 patients). Conclusions: MISA for closing ASD II proved safe and effective. A continuous evolution of MISA in our Institution was characterized by a progressive miniaturization of surgical accesses, reduced hospitalization and eventually reduced hospital costs.

Minimally Invasive Cardiac Surgery Without Peripheral Cannulation: A Single Centre Experience

A minimally invasive approach without any peripheral cannulation was used as an alternative to median sternotomy for the correction of a wide range of cardiac defects with superior results and good cosmetic outcome. From October 2015 to March 2017, 145 patients underwent correction of congenital cardiac malformations with cardiopulmonary bypass through right anterior minithoracotomy (RAMT) with routine cannulation. The average age was 9.69±4.38years (range 2-21) and the average body surface area was 0.91±0.27square metres (range 0.5-1.7). The corrected defects included all types of atrial septal defect (ASD) and ventricular septal defects (VSD), partial atrioventricular septal defects with severe mitral regurgitation, mitral valve repair, repair of tetralogy physiology requiring outlet patch enhancement, isolated pulmonary stenosis (PS) and congenital coronary cameral fistula. There was no operative mortality or major morbidity. All patients were alive at the time of this follow-up. The mean cardiopulmonary bypass time was 64.75±22.28minutes (range 30-175) and mean aortic cross clamp time was 37.53±18.23minutes (range 14-135). Fifty-five (55) patients were extubated in the operating room and the remaining 90 patients were extubated within 3hours in the intensive care unit. Repair and cosmetic results were excellent in all patients. There were no conversions to full sternotomy. No neurological events were reported. Right anterior minithoracotomy without peripheral cannulation is safe and effective for the correction of a wide range of congenital heart defects including right ventricular outlet obstructions. The cosmetic results are satisfactory, avoiding psychosocial problems.

Video assisted right mini-thoracotomy for aortic valve replacement.

Aortic valve replacement through minimally invasive access is increasing. These procedures have several advantages over conventional sternotomy including decreased intensive care unit and hospital length of stay and decreased ventilation time. The right anterior mini-thoracotomy (RAM) approach is potentially attractive in that it completely spares the sternum leading to improved cosmesis, reduced blood loss, and improved patient satisfaction. However, this approach is underutilized due to anticipated technical challenges including difficulty with visualization and annular suture placement. We employ a camera and automated suturing technology for supra-annular valve implant. A RAM is performed via a 5 cm incision in the right second intercostal space with a camera port placed lateral to the incision. Peripheral venous cannulation is performed along with central arterial cannulation. Aortic cross clamp is placed through a 5 mm incision in the third interspace anterior to mid axillary line. Histidine tryptophan ketoglutarate (HTK) cardioplegia is administered. After aortic leaflet removal, annular and prosthetic sutures are placed with shafted instruments or with automated suturing technology. Aortic valve replacement can be performed safely through a RAM. The use of a camera and automated suturing technology facilitates this procedure, potentially enabling more surgeons to offer this less invasive approach to patients.

Minimally Invasive Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: Propensity Matched Initial Experience

Aortic valve replacement by way of a right anterior mini-thoracotomy (RAMT) has shown excellent results in terms of mortality and morbidity. The aim of the present study was to compare RAMT aortic valve replacement (AVR) with conventional full sternotomy in regards to early perioperative outcomes and mortality. This was a retrospective, observational, cohort study of prospectively collected data from patients who underwent isolated, first time AVR between January 2013 and October 2016. Fifty-three RAMT patients were matched to a control group (conventional full sternotomy) using propensity score analysis. The characteristics of the two cohorts were similar. The in-hospital mortality was 1.9% utilising the RAMT approach versus 5.7% using the sternotomy approach (p=0.34). Ventilation times were similar in both groups (7 [5-2] vs 8 [5-13] hrs; p=0.61). However, ICU length of stay was significantly longer in the RAMT group (median, 46.5 [23-59.5] vs 20 [14-23] hrs; p<0.001), which translated into a significantly longer postoperative hospital length of stay for the RAMT group (median, 8 [6-12] vs 6 [5.5-9.5] days; p=0.04) compared to the sternotomy group. RAMT was associated with a trend towards a higher incidence of postoperative AF in comparison to the sternotomy group, although this was not statistically significant (41.5% vs 28.3%; p=0.17). Patients in the RAMT group had lower 4-hour chest drain output (102.5 vs 1141ml; p=0.0.07). There was no statistically significant difference in rates of non-red cell transfusions between the two groups, (17%vs28.3%; p=0.10). The occurrence of stroke, re-exploration for bleeding, red-cell transfusion and wound infection was similar in both groups. Right anterior mini-thoracotomy in patients undergoing isolated aortic valve surgery is a safe approach in select patients, although associated with longer cardiopulmonary bypass times and ICU length of stay.

Anaesthesia for trans-aortic Transcatheter Aortic Valve Replacement (TAVI-ta – does single-lung ventilation have an impact?

IntroductionTAVI-ta has become an alternative for selected patients and can be done by partial sternotomy or right-anterior mini thoracotomy (RAMT). Single-lung ventilation (SLV) may be necessary for RAMT. Isolation of the right lung may induce a shunt of about 50% and further lead to hypoxemia. We hypothesized that patients with SLV had a lower perioperative arterial partial pressure (PaO2). Furthermore we hypothetized that SLV-patients had a higher need of catecholaminergic therapy.MethodData for this pilot trial was retrieved from our prospective registry. We compared patients undergoing TAVI-ta in RAMT with and without SLV usage. Initiation and duration of SLV was at the discretion of the interventionalist. Arterial blood gas analysis (ABG) was analyzed before induction (room air), after induction (FiO2 1.0), 20 minute after initiation of SLV (or corresponding if SLV was not used) and on admission to ICU.ResultsBetween June 2008 and December 2014 62 patients underwent TAVI-ta. In 44/62 RAMT was chosen. SLV was used in 30/44 patients. Patient characteristics, ABG and catecholamine use are shown in the table. Median [IQR] ELV duration was 65 [30/85] min.DiscussionTabled 1no SLVSLVp-valuen= 14n=30Age (yrs)81 (78-86)82 (79-84)0.484EuroSCORE log (%)33.29 (20.07-42.53 )19.64 (15.76-35.30)0.300Euroscore II (%)10.14 (5.55-12.57)8.66 (3.46-12.95)0.441STS Mortality (%)10.16 (8.62-10.84)8.30 (3.79-18.00)0.447Ejection Fraction (%)35 (31-55)45 (30-60)0.320Aortic Valve Area (cm2)0.70 (0.60-0.86)0.60 (0.60-0.85)0.390Use of Caecholamines (n=)13 (92%)27 (90%)1.000Dosage Norepinephrine (mcg/kg)3.7 (2.2-7.0)7.1 (3.2-10.7)0.187Duration Anaesthesia (Min)215 (200-240)240 (208-278)0.046PaO2 before induction (mmHg)79 (69.9-88.5)74.5 (70.9-88.9)0.885PaCO2 before induction (mmHg)38 (37-40)36.6 (30.0-41.8)0.469PaO2 after induction (mmHg)337.6 (222.3-395.2)363.4 (340.9-413.1)0.422PaCO2 after induction (mmHg)45 (37.3-50.0)41 (36.6-46.9)0.454PaO2 during SLV (mmHg)219.3 (81.1-317.9)150.7 (111.6-301.9)0.865PaCO2 during SLV (mmHg)47.4 (42.3-55.4)45.6 (42.8-54.1)0.654PaO2 Admission ICU (mmHg)152.7 (115.8-202.2)118.9 (93.4-140.9)0.291PaCO2 Admission ICU (mmHg)41.5 (38.8-43.9)41.6 (35.8-46.8)0.928In-hospital mortality (n=)01 (3%)0.333Length of hospital stay (d)9 (8-17)11 (8-14)0.796 Open table in a new tab IntroductionTAVI-ta has become an alternative for selected patients and can be done by partial sternotomy or right-anterior mini thoracotomy (RAMT). Single-lung ventilation (SLV) may be necessary for RAMT. Isolation of the right lung may induce a shunt of about 50% and further lead to hypoxemia. We hypothesized that patients with SLV had a lower perioperative arterial partial pressure (PaO2). Furthermore we hypothetized that SLV-patients had a higher need of catecholaminergic therapy. TAVI-ta has become an alternative for selected patients and can be done by partial sternotomy or right-anterior mini thoracotomy (RAMT). Single-lung ventilation (SLV) may be necessary for RAMT. Isolation of the right lung may induce a shunt of about 50% and further lead to hypoxemia. We hypothesized that patients with SLV had a lower perioperative arterial partial pressure (PaO2). Furthermore we hypothetized that SLV-patients had a higher need of catecholaminergic therapy. MethodData for this pilot trial was retrieved from our prospective registry. We compared patients undergoing TAVI-ta in RAMT with and without SLV usage. Initiation and duration of SLV was at the discretion of the interventionalist. Arterial blood gas analysis (ABG) was analyzed before induction (room air), after induction (FiO2 1.0), 20 minute after initiation of SLV (or corresponding if SLV was not used) and on admission to ICU. Data for this pilot trial was retrieved from our prospective registry. We compared patients undergoing TAVI-ta in RAMT with and without SLV usage. Initiation and duration of SLV was at the discretion of the interventionalist. Arterial blood gas analysis (ABG) was analyzed before induction (room air), after induction (FiO2 1.0), 20 minute after initiation of SLV (or corresponding if SLV was not used) and on admission to ICU. ResultsBetween June 2008 and December 2014 62 patients underwent TAVI-ta. In 44/62 RAMT was chosen. SLV was used in 30/44 patients. Patient characteristics, ABG and catecholamine use are shown in the table. Median [IQR] ELV duration was 65 [30/85] min. Between June 2008 and December 2014 62 patients underwent TAVI-ta. In 44/62 RAMT was chosen. SLV was used in 30/44 patients. Patient characteristics, ABG and catecholamine use are shown in the table. Median [IQR] ELV duration was 65 [30/85] min. DiscussionTabled 1no SLVSLVp-valuen= 14n=30Age (yrs)81 (78-86)82 (79-84)0.484EuroSCORE log (%)33.29 (20.07-42.53 )19.64 (15.76-35.30)0.300Euroscore II (%)10.14 (5.55-12.57)8.66 (3.46-12.95)0.441STS Mortality (%)10.16 (8.62-10.84)8.30 (3.79-18.00)0.447Ejection Fraction (%)35 (31-55)45 (30-60)0.320Aortic Valve Area (cm2)0.70 (0.60-0.86)0.60 (0.60-0.85)0.390Use of Caecholamines (n=)13 (92%)27 (90%)1.000Dosage Norepinephrine (mcg/kg)3.7 (2.2-7.0)7.1 (3.2-10.7)0.187Duration Anaesthesia (Min)215 (200-240)240 (208-278)0.046PaO2 before induction (mmHg)79 (69.9-88.5)74.5 (70.9-88.9)0.885PaCO2 before induction (mmHg)38 (37-40)36.6 (30.0-41.8)0.469PaO2 after induction (mmHg)337.6 (222.3-395.2)363.4 (340.9-413.1)0.422PaCO2 after induction (mmHg)45 (37.3-50.0)41 (36.6-46.9)0.454PaO2 during SLV (mmHg)219.3 (81.1-317.9)150.7 (111.6-301.9)0.865PaCO2 during SLV (mmHg)47.4 (42.3-55.4)45.6 (42.8-54.1)0.654PaO2 Admission ICU (mmHg)152.7 (115.8-202.2)118.9 (93.4-140.9)0.291PaCO2 Admission ICU (mmHg)41.5 (38.8-43.9)41.6 (35.8-46.8)0.928In-hospital mortality (n=)01 (3%)0.333Length of hospital stay (d)9 (8-17)11 (8-14)0.796 Open table in a new tab

Sutureless Aortic Valve Prosthesis Sizing: Estimation and Prediction Using Multidetector-Row Computed Tomography.

The sutureless prostheses may facilitate minimally invasive aortic valve replacement because of easy and fast deployment. However, correct device sizing remains a crucial step of this procedure, which may be difficult and time consuming in minimal invasive approaches. We sought to analyze the accuracy of contrast-enhanced preoperative multidetector-row computed tomography (MDCT) in predicting the size of the prosthesis to be implanted in patients undergoing aortic valve replacement through a right anterior minithoracotomy (RAMT). From January 2011 to September 2013, 235 patients underwent aortic valve surgery as sole procedure with implantation (Sorin Perceval S) in RAMT. Inclusion criterion for this study was presence of preoperative multidetector-row computed tomography (MDCT) with contrast enhancement and Doppler echocardiography. A preoperative MDCT was used to measure the aortic annulus as the diameter derived from either the area (aD) or the circumference (cD) of the virtual basal ring, left ventricular outflow tract (LVOT) diameter derived either from the area (aLVOT) or the circumference (cLVOT). Multidetector-row CT was reviewed by a single operator who was blind to implanted valve size. The operator measured the aortic annulus and LVOT in multiplanar reconstruction modality. Aortic annular diameter and LVOT diameter were retrieved from echocardiographic records. Predictive models were built based on logistic regression; outcome variable was the sutureless valve size, and covariates (annular and LVOT measurements) were used as single and multivariate predictors. A classification tree was built and then pruned with limited nodes to be able to obtain better predictive performance. We identified 54 patients who had preoperative contrast-enhanced MDCT. Seven patients received a size S, 21 received a size M, and 26 received a size L prosthesis. The mean age of the patients at the time of intervention was 76.3 ± 6.8 years, and the mean logistic EuroSCORE was 10.4% ± 8.7%. Echocardiographic measurements showed lower accuracy compared to MDCT measurements. Echocardiographic LVOT measurement was 61.11% to predict the valve size, whereas annulus measurement was 53.7%. The aLVOT from MDCT had an accuracy of approximately 62.96%, and cLVOT had 64.81% predictive accuracy. Aortic annulus perimeter cD had the highest accuracy to predict the valve size [62.96%, under the curve, 0.61] followed by aortic annular surface aD having an accuracy of approximately 70.37% (under the curve, 0.75). Classification tree models, after pruning with 4 nodes, increased their accuracy (83.33%), and it was easy to interpret and possibly to implement for clinical use. Multidetector-row CT-derived estimates seem to have higher predictive value for valve size determination in patients undergoing RAMT with the Perceval S prosthesis, thus facilitating this delicate procedure and preventing the selection of wrong candidates. Possibly for precise aortic annulus measurement, contrast-enhanced MDCT is preferable.

Right anterior minithoracotomy for aortic valve replacement: 10-year experience of a single center

ObjectiveMinimally invasive aortic valve replacement (AVR) has been associated with several better outcomes over the standard full sternotomy approach. We revised our 10-year experience with right anterior minithoracotomy (RAMT) for AVR. MethodsBetween 2004 and 2014, a total of 593 patients (310 men; median age: 73.8 years) underwent AVR via RAMT. Preoperatively, a mixed valve lesion was diagnosed in 55 (9.3%) patients; and pure aortic regurgitation in 86 (14.5%). Mean logistic EuroSCORE I (European system for cardiac operative risk evaluation) was 7.4 (median: 5.76). ResultsIn 302 (50.9%) patients, a sutureless or rapidly implantable biological prosthesis was used; in 23 (3.9%), a mechanical prosthesis; and in the remainder, a conventional biological prosthesis. A total of 113 (19.1%) patients had a small aortic annulus (≤21 mm). Operative times averaged 80 (median: 74) minutes of crossclamping time, and 117 (107) minutes of perfusion time; these were significantly shorter with a sutureless prostheses, compared with a sutured prostheses: perfusion 99 versus 134 minutes, P < .0005; aortic crossclamping time: 64 versus 97 minutes, P < .0005. The mean (median) assisted ventilation time was 9.8 (6) hours; intensive care unit stay was 1.5 (1) days; hospital length of stay was 6.6 (6) days. Overall in-hospital mortality was 9 deaths (1.5%). At 31.5 months mean follow-up time (1531 cumulative patient-years), 94.8% survival was observed. ConclusionsMinimally invasive AVR is a safe procedure, with low perioperative morbidity, and low rates of reoperation and death at late follow-up. Excellent outcomes can be achieved with minimally invasive AVR via right anterior minithoracotomy. Sutureless prostheses facilitate minimally invasive AVR and are associated with reduced operative times.

Minimally invasive aortic valve replacement with a sutureless valve through a right anterior mini-thoracotomy versus transcatheter aortic valve implantation in high-risk patients.

The aim of this study was to compare early outcomes and mid-term survival of high-risk patients undergoing minimally invasive aortic valve replacement through right anterior mini-thoracotomy (RT) with sutureless valves versus patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. From October 2008 to March 2013, 269 patients with severe aortic stenosis underwent either RT with perceval S sutureless valves (n = 178 patients, 66.2%) or TAVI (n = 91, 33.8%: 44 transapical and 47 trans-femoral). Of these, 37 patients undergoing RT with the perceval S valve were matched to a TAVI group by the propensity score. Baseline characteristics were similar in both groups (mean age 79 ± 6 years) and the median logistic EuroSCORE was 14% (range 9-20%). In the matched group, the in-hospital mortality rate was 8.1% (n = 3) in the TAVI group and 0% in the RT group (P = 0.25). The incidence rate of stroke was 5.4% (n = 2) versus 0% in the TAVI and RT groups (P = 0.3). In the TAVI group, 37.8% (n = 14) had mild paravalvular leakage (PVL) and 27% (n = 10) had moderate PVL, whereas 2.7% (n = 1) had mild PVL in the RT group (P < 0.001). One- and 2-year survival rates were 91.6 vs 78.6% and 91.6 vs 66.2% in patients undergoing RT with the perceval S sutureless valve compared with those undergoing TAVI, respectively (P = 0.1). Minimally invasive aortic valve replacement with perceval S sutureless valves through an RT is associated with a trend of better early outcomes and mid-term survival compared with TAVI.

Right anterior minithoracotomy for aortic valve replacement.

We present the case of a 78-year-old lady with severe aortic stenosis who underwent cardiovascular investigations for ingravescent dyspnea [New York Heart Association (NYHA) functional class III] undergoing minimally invasive aortic valve replacement (MIAVR) through right anterior minithoracotomy (RT). The patient’s height and weight were 170 cm and 62 kg, respectively. Risk factors included hypertension, diabetes, hypercholesterolemia and chronic obstructive pulmonary disease. Transthoracic echocardiography showed a mean aortic transvalvular gradient of 52 mmHg and peak gradient of 88 mmHg. Left ventricular ejection fraction was 45% and systolic pulmonary artery pressure was 50 mmHg.