Right Minithoracotomy Research Articles

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17269 patients.

Aortic valve replacement (AVR) is a common procedure for aortic valve pathologies, particularly in the elderly. While traditional open AVR is established, minimally invasive techniques aim to reduce morbidity and enhance treatment outcomes. The authors' meta-analysis compares these approaches with conventional sternotomy, offering insights into short and long-term mortality and postoperative results. This study provides valuable evidence for informed decision-making between conventional and minimally invasive approaches for AVR. Till August 2023, PubMed, Embase, and MEDLINE databases were searched for randomized controlled trials (RCT) and propensity score matched (PSM) studies comparing minimally invasive approaches [mini-sternotomy (MS) and right mini-thoracotomy (RMT)] with full sternotomy (FS) for AVR. Various outcomes were analyzed, including mortality rates, bypass and clamp times, length of hospital stay, and complications. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% CIs were calculated using Review Manager. Forty-eight studies were included having 17269 patients in total. When compared to FS, there was no statistically significant difference in in-hospital mortality in MS (RR:0.80; 95% CI:0.50-1.27; I2=1%; P=0.42) and RMT (RR:0.70; 95% CI:0.36-1.35; I2=0%; P=0.29). FS was also linked with considerably longer cardiopulmonary bypass duration than MS (MD:8.68; 95% CI:5.81-11.56; I2=92%; P=0.00001). The hospital length of stay was determined to be shorter in MS (MD:-0.58; 95% CI:-1.08 to -0.09; I2=89%; P=0.02) with no statistically significant difference in RMT (MD:-0.67; 95% CI:-1.42 to 0.08; I2=84%; P=0.08) when compared to FS. While mortality rates were comparable in minimally invasive approaches and FS, analysis shows that MS, due to fewer respiratory and renal insufficiencies, as well as shorter hospital and ICU stay, may be a safer approach than both RMT and FS.

MID–TERM OUTCOMES OF ENDOSCOPIC MITRAL VALVE REPAIR VIA RIGHT ANTERIOR MINI–THORACOTOMY

Abstract The adoption of less–invasive mitral repair (MVr) surgery is increasing, backed by evidence of satisfactory short–term results and lower major morbidity. We assessed mid–term follow–up results of our experience, and compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet (PML) prolapse. Between 2012–2021, 700+ operations were performed with a video–assisted right mini–thoracotomy (RMT) approach. We report 309 consecutive patients who had endoscopic MVr, including those receiving concomitant tricuspid repair, ablation for atrial fibrillation, closure of patent foramen ovale and/or left atrial appendage. The early and mid–term follow–up results were ascertained. Primary outcome was the incidence of mortality and significant mitral regurgitation (MR) during follow–up which were summarized by Kaplan–Meier estimator and compared between treatment arms via log–rank test. Secondary outcomes were the early–postoperative results including 30–days mortality and major complications. All patients had endoscopic MVr via RMT at the 3rd/4th intercostal space (IS). A soft–tissue retractor is used, accompanied or not by a rib spreader, and two ports in the fourth and sixth IS are used for 3D thoracoscopy and carbon dioxide insufflation. Femoral vessels exposure through a right groin incision and echo–guided cannulation sec. Seldinger is achieved post–heparinization. Thoracic fascia bisection is performed during single–lung ventilation using a double–lumen endotracheal tube, integral to our anesthetic management, including percutaneous right internal jugular vein cannulation. The pericardium is opened and an aortic root cannula for cardioplegia delivery and venting is placed via working incision. After establishing cardiopulmonary bypass, a Chitwood clamp is passed through the second IS and cardioplegia is delivered. Endoaortic balloon clamping is primarily used in redo cases. With ring annuloplasty, 136 (44%) patients received PML resection (122 isolated) and 97 (31%) PML chords implantation (88 isolated). Forty–nine patients had annuloplasty alone. In–hospital mortality was 1.0%. Mean follow–up was 29±22 months (max 8.3 years). Kaplan–Meier 5–year survival was 97.3±1.0%. MR (3/4+) free–survival at 5 years was 94.5±2.3%. Subgroup time–to–event analysis for the indexed outcomes showed no statistical significance between techniques. In conclusion, endoscopic MVr is safe with excellent mid–term outcomes.

Minimally Invasive Mitral Valve Surgery With Concomitant Cox Maze Procedure Is as Effective as a Median Sternotomy With Decreased Morbidity.

A right minithoracotomy (RMT) is a minimally invasive surgical approach that has been increasingly performed for the concomitant Cox maze IV procedure (CMP) and mitral valve surgery (MVS). Little is known regarding whether long-term rhythm and survival outcomes are affected by the RMT as compared with the traditional median sternotomy (MS) approach. Between April 2004 and April 2021, 377 patients underwent the concomitant CMP and MVS, of whom 38% had RMT. Propensity score matching yielded 116 pairs. Freedom from atrial tachyarrhythmias (ATA) was assessed with prolonged monitoring annually for 8 years. Survival, rhythm, and perioperative outcomes were compared. The unmatched RMT cohort had a greater freedom from ATA recurrence at 1 year (99% vs 90%, P = 0.001) and 3 years (94% vs 86%, P = 0.045). The matched RMT cohort had longer cardiopulmonary bypass (median: 215 [199 to 253] vs 170 [136 to 198] min, P < 0.001) and aortic cross-clamp (110 [98 to 124] vs 86 [71 to 102] min, P < 0.001) times but shorter intensive care time (48 [24 to 95] vs 71 [26 to 144] h, P = 0.001) and length of stay (8 [6 to 11] vs 10 [7 to 14] h, P < 0.001). More pacemakers (18% vs 4%, P < 0.001) and postoperative transfusions (57% vs 41%, P = 0.014) occurred in the MS cohort. The 30-day mortality (P = 0.651) and 8-year survival (P = 0.072) was not significantly different between the cohorts. Early 1-year and 3-year freedom from ATA recurrence was better in the RMT cohort compared with the MS cohort. Despite longer operative times, the RMT cohort had shorter lengths of stay, fewer postoperative transfusions, and fewer pacemakers placed.

Outcomes and residual gap analysis after the modified cryomaze procedure performed via right minithoracotomy versus sternotomy

ObjectivesDevelopments in both technique and technology have enabled surgeons to perform the maze procedure via right minithoracotomy (RMT) to treat atrial fibrillation (AF). This study aimed to clarify the outcomes of the modified cryomaze procedure via the RMT approach compared with the sternotomy approach. MethodsThe study cohort comprised 803 consecutive patients who underwent a modified cryomaze procedure (130 via RMT and 673 via sternotomy) for paroxysmal AF and persistent AF from January 2001 to March 2022. The Gray test was applied to compare the incidence of recurrent atrial tachyarrhythmias. Additionally, residual electrical gaps were investigated in the patients who underwent additional catheter ablation for recurrent atrial tachyarrhythmias. ResultsThe respective 1-, 2-, and 3-year cumulative incidences of recurrent atrial tachyarrhythmias were 13.1%, 19.5%, and 23.1% in the RMT group, and 9.3%, 10.9%, and 12.8% in the sternotomy group (Gray test P = .036). All 31 patients with recurrent atrial tachyarrhythmias underwent additional catheter ablation, comprising 14 (10.8%) in the RMT group and 17 (2.5%) in the sternotomy group. There was a significant intergroup difference in the site of residual electrical gaps; the RMT group more frequently had residual gaps in the tricuspid annulus than the sternotomy group (6.2% vs 0.4%; P < .001). ConclusionsIn the modified cryomaze procedure via the RMT approach, ablation failure is more likely to occur at the tricuspid annulus, where the surgical field of view is relatively poor compared with the sternotomy approach. Therefore, surgical ablation should be performed with caution when the RMT approach is used.

Minimally invasive versus conventional aortic valve replacement: The network meta-analysis.

Outcome comparisons after surgical aortic valve replacement (SAVR) with minimally invasive approaches including mini-sternotomy (MS) and right mini-thoracotomy (RMT) and full sternotomy (FS) have been conflicting. Furthermore, the synthesis of mid-term mortality has not been performed. MEDLINE and EMBASE were searched through April 2022 to identify propensity score matched (PSM) studies or randomized controlled trial (RCT) which compared outcomes following SAVR among three incisional approaches: FS, MS, or RMT. The network analysis was performed to compare these approaches with random effects model. Mid-term mortality was defined as 1-year mortality. A total of 42 studies met the inclusion criteria enrolling 14,925 patients. RCT and PSM were performed in 13 and 29 studies, respectively. The operative mortality was significantly lower with MS compared to FS (risk ratio [RR]: 0.60, 95% confidence interval [CI]: 0.41-0.90, p = .01, I2 = 25.8%) or RMT (RR: 0.51, 95% CI: 0.27-0.97, p = .03, I2 = 25.8%). RMT had significantly higher risk of reoperation for bleeding compared to MS (RR: 1.65, 95% CI: 1.18-2.30, p = .003, I2 = 0%). Hospital length of stay was significantly shorter with MS compared to FS (mean difference: -0.89 days, 95% CI: -1.58 to -0.2, p = .01, I2 = 95.5%) while it was equivocal between FS and RMT. The mid-term mortality was similar among the three approaches. While mid-term mortality was comparable among approaches, MS may be a safe and potentially more effective approach than FS and RMT for SAVR in the short term.

Propensity-matched comparison of right mini-thoracotomy versus median sternotomy for isolated mitral valve repair

A right mini-thoracotomy (RT) versus median sternotomy (MS) approach for isolated mitral valve (MV) repair has been associated with less postoperative morbidity, shorter hospital stay, and faster functional recovery, but with consistently longer cross-clamp time and higher operative costs. We assessed the impact of a modified operative technique on outcomes in 158 RT versus 129 MS patients treated with myxomatous MV repair from 2016 through 2021. Propensity matching based upon the Society of Thoracic Surgeons Risk Score was used to compare 108 patients in each cohort. Propensity-matched RT patients had reductions in total ventilation time (P=0.025), postoperative atrial fibrillation (P=0.019), and hospital length of stay (P<0.001). RT and MS patients had similar cross-clamp times (66.4±13.7 vs 64.8±16.0 minutes, P=0.414), with less overall leaflet resection (32.4% vs 57.4%, P<0.001) and fewer Gore-Tex NeoChords implanted per patient (1.7±0.7 vs 2.1±1.0, P=0.028) in the RT group. The two cohorts did not differ with respect to 30-day major surgical complications. No patient died and there was no difference between the two groups with respect to freedom from re-operation (98.2% vs 98.2%, P=0.800) at a mean follow-up of 21.4±18.5 months. Direct total hospital costs were lower for the RT group (P=0.018), with reductions in postoperative charges offsetting increased operating room costs. In this single-center study, the RT compared to the MS approach for myxomatous MV repair resulted in less postoperative morbidity and shorter hospital length of stay, with similar cross-clamp time, reduced total hospital costs, and comparable intermediate outcomes.

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.

Perioperative incidence of ECMO and IABP on 5901 mitral valve surgery procedures

BackgroundReport the incidence and results of peri-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) of patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) and conventional full sternotomy (FS) for a period of 6 years from eleven tertiary Cardiac Surgery Institutes of GVM Care & Research Italia.MethodsFrom January 2016 to November 2021, a total of 5901 consecutive patients underwent MVS through RT and FS. The primary outcome of the study was the mortality and incidence of low cardiac output syndrome (LCOS) treated with intra-aortic balloon pump (IABP) with or without inotropic support and the incidence of Postcardiotomy Cardiogenic Shock (PCS) treated with Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) on patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) versus conventional full sternotomy (FS).ResultsThe mean age was 66 ± 15 years, 3389 patients underwent in RT approach 2512 in FS, 3081 (52%) patients were male and 2.3% had previous cardiac operations. Cardiopulmonary bypass time was 93 min for RT and 81 min for FS and cross clamp time 75 min for RT and 63 min for FS for mitral valve repair. Incidence of perioperative IABP for the treatment of low cardiac output was reported on 99 patients (1.6%), 51 for RT (1.5%), 35% used inotropic support (adrenaline and milrinone) and 48 in FS (1.9), 28% use inotropic support, 21 patients died after IABP (3 RT and 18 FS). Incidence of perioperative VA-ECMO for the PCS treatment was 13 and 4 with IABP, 9 RT (0.2%) and 4 FS approach (0.15%), 12 patients died after VA-ECMO.ConclusionMinimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity. ECMO and IABP incidence for the treatment of PCS was 0.2% and for Low cardiac output syndrome (LCOS) was 1.6% in elective mitral valve surgery is very low. The patients that use the perioperative IABP in minimally invasive mitral valve surgery (MIMVS) trough RT reported a reduced mortality compared to FS in relation to the operative risk and surgical technique. Low incidence of VA-ECMO was found in RT and FS approach, only one patient survived after VA-ECMO after minimally invasive mitral valve surgery.

Comparative Early and Long Term Results of Mitral Valve Surgery between Right Mini Thoracotomy and Full Sternotomy Approach

Background: Conventional mitral valve surgery (MVS) requires median sternotomy. Right mini thoracotomy (RMT) MVS is an alternative non sternotomy approach aiming for less bleeding, pain reduction, rapid recovery, cosmetic satisfaction, safety and effectiveness of the procedure. Objectives: To report early and late clinical results comparing RMT versus full sternotomy (FS) MVS. Materials and Methods: 574 consecutive patients underwent MVS were prospectively non randomized reviewed during January 2002 to October 2018. There were 241 in FS group and 241 in RMT group by age and Euro II score matching. Baseline characteristics were compared. Early and late clinical outcomes of 30 days mortality, reoperation for bleeding, stroke, prolonged ventilation, renal failure, permanent pacemaker, and echocardiographic hemodynamic performance were assessed and compared between two groups. All patient follow-up to December 2020. Results: Similar results were found between RMT and FS MVS groups including age 58.8+13.6, 57.2+14.2, p=0.2, new AF 5 (2%), 4 (1.7%), p=1.0), except for more degenerative valve pathology (79%, 50%, p&lt;0.001). There were more re operation for bleeding 2 (0.8%), 1 (0.3%), p=0.9, less aortic cross clamp time (107+37.3, 115.4+36.4, p=0.017), less cardiopulmonary bypass time (157.6+51.2, 171.3+53.4, p=0.005), less bleeding and blood transfusion requirement in the RMT group. Early clinical results of 30 days mortality, stroke, renal failure, new pacemaker, and hemodynamic performance at one month, three to six month, and one year were comparable in both groups. Mean follow-up (year) was 5.2+2.5 (RMT) and 10.2+4.0 (FS). Survival probability and freedom from MACCE at ten years in RMT and FS group were 94.05%, 95.44% and 99.5%, 90.46%, p&lt;0.001, respectively. Conclusion: RMT approach for MVS is associated with cosmetic satisfaction, less bleeding, similar effective hemodynamic performance and non-inferiority early and late clinical results to FS approach. Keywords: Mitral valve surgery; Right mini thoracotomy

Right mini-thoracotomy versus median sternotomy for mitral valve replacement

Background: The advantages of minimally invasive mitral valve surgery over the conventional approach is still debated. This study aimed to evaluate early outcomes after mitral valve replacement (MVR) using the right mini-thoracotomy (RMT) versus median sternotomy (MS).&#x0D; Methods: We prospectively included 60 patients who had MVR from May 2015 to June 2017. We classified patients into two groups; Group A (n= 30) had RMT, and Group B (n= 30) had MS. Postoperative pain score, wound satisfaction, and clinical and echocardiographic outcomes were compared between both groups.&#x0D; Results: The mean age was 39.90 ± 12.34 years in Group A and 45.75 ± 13.10 years in Group B (p= 0.08). Preoperative and echocardiographic data showed no statistical significance difference between the groups. Group A had longer aortic cross-clamp (118.85 ± 40.56 vs. 70.75 ± 24.81 minutes, p&lt;0.001) and cardiopulmonary bypass times (186.70 ± 67.44 vs. 104.65 ± 42.60 minutes, p&lt;0.001). Group B had more blood loss (565 ± 344.3 vs. 241.5 ±89.16 ml/24 hours, p&lt;0.001). The median pain score was 1 (range: 1- 3) in Group A and 4 (2- 8) in Group B (p&lt;0.001), and the median wound satisfaction was 1.5 (1- 4) in Group A and 4 (1- 7) in Group B (p&lt;0.001). Wound infection occurred in 1 (3.3%) patient in Group A and 6 (20%) patients in Group B (p=0.04).&#x0D; Conclusion: Mitral valve replacement through the right mini-thoracotomy could be a safe alternative to median sternotomy. The right mini-thoracotomy was associated with longer operative times but better pain and wound satisfaction scores and lower wound infection.

Early and mid-term outcomes of minimally invasive mitral valve repair via right mini-thoracotomy: 5-year experience with 129 consecutive patients

ObjectivesThis study analyzed the experience of a single institution with minimally invasive mitral valve repair (MIMVr) via a right mini-thoracotomy (RT), including short and mid-term morbidity and mortality as surgical outcomes, and rates of reoperation. Late follow-up findings regarding mitral regurgitation (MR) were also assessed.MethodsBetween January 2014 and January 2020, a total of 141 consecutive patients underwent MIMVr for mitral regurgitation at our institution via an RT, with late follow-up results (median 35 ± 15 months) available for 129 (91.4%). Findings regarding surgical approach, complications, reoperations, and late survival were examined. Late echocardiographic results showing recurrence of MR after mitral repair were also noted. Survival, freedom from reoperation, and recurrent MR (grade > 2) were evaluated by Kaplan–Meier analysis.ResultsMean age was 63.9 ± 14.3 years, mean ejection fraction was 66.9 ± 10.4%, and 2 patients (1.6%) underwent a reoperation. Concomitant procedures included atrial fibrillation ablation (18%), tricuspid valve surgery (16%). None (0%) experienced intraoperative conversion to sternotomy. A learning curve was observed as the number of cases increased. Overall in-hospital mortality and stroke incidence were both 0%. Freedom from recurrent MR (grade > 2) at 1, 3, and 5 years was 99.2, 94.9, and 94.9%, respectively, while freedom from reoperation at 1, 3, and 5 years after mitral valve repair was 98.4, 98.4, and 98.4%, respectively.ConclusionsEarly and mid-term results of MIMVr were satisfactory, with low rates of perioperative morbidity and recurrent MR, as well as reoperation and death. Furthermore, the protocols for patient selection and surgical approach were considered to be appropriate.

The Effect of Continuous Field Block through Intercostal Muscles after Atrial Septal Defect Closure via a Mini-Right Thoracotomy in Pediatric Patients.

Postoperative pain management in thoracotomy patients often is difficult. Furthermore, pediatric patients present more challenges because of their inability to effectively communicate their pain intensity. The purpose of this study was to evaluate the use of continuous field block through intercostal muscles as postoperative pain management in pediatric thoracotomy. Between 2014 and 2018, 11 patients underwent an ASD closure using a cardiopulmonary bypass via a mini-right thoracotomy through the fourth intercostal space. At the time of chest closure, a single-shot field block via the fourth intercostal muscles was performed with levobupivacaine (0.6 mg/kg). The first five patients were only given the single-shot field block (Single group). The remaining six patients were given levobupivacaine continuously (0.1 mg/kg/hr) through an indwelling catheter until the chest tube removal (Continuous group). The groups' vital signs, total amounts of acetaminophen used, postoperative courses were compared. Although the heart rate did not differ between the groups, the respiratory rate was significantly higher in the Single group versus the Continuous group at 16 and 32 hr post-surgery (35.6 ± 9.7/min vs. 18.5 ± 4.7/min; p=0.007, 43.0 ± 10.4 vs. 25.3 ± 3.1; p=0.042, respectively). The accumulated dosage of acetaminophen given by postoperative day 2 was significantly higher in the Single group versus the Continuous group (55.3 ± 22.1 mg/kg vs. 7.8 ± 17.4 mg/kg; p=0.012). Continuous field block via intercostal muscles after ASD closure via a mini-right thoracotomy in children was effective to stabilize the vital signs and reduce the analgesic medication use.

Triport periareolar thoracoscopic surgery versus right minithoracotomy for repairing atrial septal defect in adults.

Our goal was to investigate the safety and feasibility of triport periareolar thoracoscopic surgery (TPTS) and its advantages in repairing adult atrial septal defect. Between January 2017 and January 2020, a total of 121 consecutive adult patients underwent atrial septal defect closure in our institution. Of these, 30 patients had TPTS and 31 patients had a right minithoracotomy (RMT). Operational data and clinical outcomes were compared between the 2 groups. The total operation time, cardiopulmonary bypass time and aortic cross-clamp time in the TPTS group were slightly longer than those in the RMT group, but there were no differences between the 2 groups. Compared with the RMT group, the TPTS group showed a decrease in the volume of chest drainage in 24 h (98.6 ± 191.2 vs 222.6 ± 217.2 ml; P = 0.032) and a shorter postoperative hospital stay (6.5 ± 1.5 vs 8.0 ± 3.7 days; P = 0.042). The numeric rating scale on postoperative day 7 was significantly less in the TPTS group than in the RMT group (2.82 ± 1.14 vs 3.56 ± 1.42; P = 0.034). The patient satisfaction scale for the cosmetic results in the TPTS group was significantly higher than in the RMT group (4.68 ± 0.55 vs 4.22 ± 0.76; P = 0.012). No differences were found in postoperative complications. No in-hospital death or major adverse events occurred in the 2 groups. TPTS is safe and feasible for the closure of adult atrial septal defect. Compared with RMT, it has been associated with less pain and better cosmetic outcomes.

Long-Term Outcomes of Right Minithoracotomy Versus Hemisternotomy for Mitral Valve Repair.

Minimally invasive mitral valve repair has been increasingly adopted. Right minithoracotomy (RT) and lower hemisternotomy (HS) have each been associated with improved short-term outcomes; however, these approaches have not been directly compared to each other. The aim of this study was to compare long-term survival and durability of 2 minimally invasive approaches to mitral repair. We retrospectively identified all isolated mitral repairs performed via RT or HS between October 1997 and June 2018; 100 RT cases and 719 HS cases were included. Outcomes of interest were postoperative complications, long-term survival, and freedom from mitral reoperation. A Cox proportional hazard model was used to compare RT and HS to a reference cohort of full-sternotomy cases. Total observation time was 9,901 patient-years and mean follow-up time was 12.2 years. Mean age was 58±12 years in the RT group and 56±13 years in the HS group (P = 0.2). The RT group had longer bypass (143 minutes vs. 112 minutes; P < 0.001) and cross-clamp times (99 minutes vs. 78 minutes; P < 0.001) compared with the HS group. There were no differences in operative mortality or 30-day outcomes. Survival at 5, 10, and 15 years was 99% (96-100), 92% (85-100), and 69% (30-100) in the RT group and 98% (97-99), 92% (90-94), and 89% (86-92) for HS (P < 0.9). There were no differences in risk-adjusted survival between RT, HS and full sternotomy. No long-term mitral reoperations occurred in the RT group and 8 (1%) occurred in the HS group (P < 0.50). Minimally invasive mitral valve repair can be performed safely through RT or HS with excellent survival and durability at 15 years.

Right minithoracotomy versus conventional median sternotomy for patients undergoing mitral valve surgery and Cox-maze IV ablation with entirely bipolar radiofrequency clamp.

Cox-maze IV ablation by bipolar radiofrequency clamp was considered to be only performed through median sternotomy (MS), but impossible through right minithoracotomy (RM). Now, we developed a novel technique of performing Cox-maze IV ablation entirely by bipolar clamp through RM. To compare the outcomes of RM or MS for patients undergoing mitral valve surgery and concomitant Cox-maze IV ablation with entirely bipolar clamp. All 152 patients underwent mitral valve surgery and concomitant Cox-maze IV ablation with bipolar clamp through RM (n=69) or MS (n=83) were analyzed for outcome differences. The etiology of mitral valve disease was rheumatic (n=97) and degenerative (n=55). All patients had long-standing persistent atrial fibrillation (AF). Diameter of left atrium ranged from 42 to 60mm. All patients successfully underwent Cox-maze IV ablation by bipolar clamp. RM group had longer cardiopulmonary bypass time (130.3±17.7 vs 115.3±14.4min; P<0.001) and aortic cross-clamp time (91.8±12.7 vs 74.6±9.3min; P<0.001). But mechanical ventilation time (14.2±6.6 vs 21.3±9.0h; P<0.001) and hospital length of stay (9.3±2.6 vs 11.7±3.0days; P<0.001) were shorter in RM group. At discharge, the maintenance of normal sinus rhythm (NSR) was 94.2% in RM group and 95.1% in MS group (P=1.000). Cumulative maintenance of NSR at 2years postoperatively was 85.1±5.8% in RM group and 88.6±3.6% in MS group (P=0.767). RM can achieve similar therapeutic effect to MS for patients undergoing mitral valve surgery and concomitant Cox-maze IV ablation with entirely bipolar clamp. In addition, patients through RM had faster recovery.

A technique of minimally invasive aortic valve replacement: an alternative to transcatheter aortic valve replacement (TAVR)

Minimally invasive aortic valve replacement (AVR) is increasingly being adopted worldwide, in which a right mini-thoracotomy (RT) approach plays an important role. Here we reported a novel technique of AVR via RT using sutureless prosthesis, without rib division or groin incision. Surgical access was performed through an anterior right thoracotomy with 5-cm skin incision placed in the third intercostal space. Percutaneous femoral-femoral cardio-pulmonary bypass (CPB) was applied under fluoroscopy guidance to avoid groin incision. A 5-mm stab incision was made in the right chest wall for aortic cross-clamping. A sutureless bioprosthetic valve was utilized in the limited operative field, which reduced the cross-clamp and CPB time. The patient was discharged on post-operative day 2, without obvious cross-valvar gradient, and with no pain or other complication. This report offers a more minimally invasive approach to AVR with proven durable valves, which can benefit high-risk patients.

Comparison of the Outcomes of Modified Artificial Chordae Technique for Mitral Regurgitation through Right Minithoracotomy or Median Sternotomy.

Background:Right minithoracotomy (RM) has been proven to be a safe and effective approach for mitral valve surgery, but the differences of artificial chordae technique between RM and median sternotomy (MS) were seldom reported. Here, we compared the outcomes of modified artificial chordae technique for mitral regurgitation (MR) through RM or MS approaches.Methods:One hundred and eighteen consecutive adult patients who received mitral valve repair with artificial chordae and annuloplasty for MR through RM (n = 58) or MS (n = 60) from January 2006 to January 2015 were analyzed.Results:All of the selected patients underwent mitral valve repair successfully without any complication during the surgery. There was no significant difference between RM group and MS group in cardiopulmonary bypass time, aortic cross-clamp time, and early postoperative complications. However, compared with the MS group, the RM group had shorter hospital stay and faster surgical recovery. At a mean follow-up of 44.8 ± 25.0 months, the freedom from more than moderate MR was 93.9% ± 3.5% in RM group and 94.8% ± 2.9% in MS group at 3 years postoperatively. Log-rank test showed that there was no significant difference in the freedom from recurrent significant MR between the two groups (χ2 = 0.247, P = 0.619). Multivariate analysis revealed that the presence of mild MR at discharge was the independent risk factor for the recurrent significant MR.Conclusion:Right minithoracotomy can achieve the similar therapeutic effects with MS for the patients who received modified artificial chordae technique for treating MR.

Right Minithoracotomy Versus Full Sternotomy for Mitral Valve Repair: A Propensity Matched Comparison

Mitral valve (MV) repair through a right minithoracotomy (RT) is technically more demanding than through a median sternotomy (MS) and has been cited for a higher rate of reoperation, increased postoperative bleeding, thromboembolic events, poor visualization, and longer operative times. Randomized studies are not available, however, and specific characteristics of patients who undergo operation with either technique are usually highly different. Therefore, a propensity matching study was performed to reduce selection bias. A retrospective analysis was made of 745 patients, 501 in group RT (67%) and 244 in group MS (33%), who underwent isolated MV repair between 2000 and 2010. Propensity matching identified 97 matched patient pairs for comparison of functional outcome, survival, incidence of reoperation, and quality of life after MV repair. Propensity matched patients in group RT had longer cardiopulmonary bypass time (120 ± 28 versus 99 ± 30 minutes, p < 0.001) and cross-clamp time (86 ± 23.5 versus 74 ± 25 minutes, p < 0.001). Thirty-day mortality was similar for both groups (RT, 0%; MS, 1%; p= 0.13). There were no significant differences in other outcomes such as amount of red blood cell transfusion, ventilation time, and hospital stay. Five-year survival in group RT (93.5% ± 3.7%) versus group MS (87.4% ± 3.6%, p= 0.556) and freedom from MV reoperation (93.3% ± 2.9% versus 97.9% ± 1.5%, respectively; p= 0.157) were not different. Functional outcome and quality of life variables were similar. Mitral valve surgery through a right minithoracotomy is a safe procedure associated with a very low operative mortality comparable to the standard sternotomy approach. In addition to improved cosmetics, minimally invasive MV surgery provides equally durable results as the standard sternotomy approach.

Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients.

BackgroundTo report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period.MethodsFrom September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT.ResultsThe mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %.ConclusionsMinimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

Right Minithoracotomy Versus Median Sternotomy for Mitral Valve Surgery: A Propensity Matched Study

The efficacy of conventional median sternotomy versus a right minithoracotomy (RT) approach to mitral valve surgery was evaluated in a single high-volume institution. A retrospective analysis of a single institution's experience was performed using propensity matching of 1,694 patients who underwent mitral valve surgery during a 15-year period. Patients who had procedures that were not usually performed through an RT approach were excluded. Using 1:1 propensity score matching, we obtained 215 matched patients in each group for outcomes analysis. There was no difference in the median year of operation between the two groups (2002 versus 2001; p= 0.142). The RT approach was not a predictor of postoperative mortality. Predictors of mortality included increasing age, diabetes, smoking, preoperative dialysis, lung disease, advanced congestive heart failure class, and peripheral vascular disease. The RT approach was associated with less new-onset atrial fibrillation (8% versus 16%; p= 0.018), pneumonia (1% versus 5%; p= 0.049), respiratory failure (3% versus 8%; p= 0.036), and acute renal failure (2% versus 7%; p= 0.006), lower chest tube output (350 versus 840 mL; p < 0.001), and fewer red blood transfusions (2 versus 3 units; p= 0.001). Right minithoracotomy compared with median sternotomy for mitral valve surgery was associated with less postoperative atrial fibrillation, respiratory complications, acute renal failure, chest tube output, and use of packed red blood cells. Given study limitations, the RT approach for mitral valve surgery may have advantages over median sternotomy in selected patients.