Sternotomy Approach Research Articles

Comparison of three approaches for accessory lung lobectomy in the canine cadaveric model: Intercostal thoracotomy, median sternotomy, and a transdiaphragmatic approach combined with caudal median sternotomy.

To describe a combined transdiaphragmatic and caudal median sternotomy (TDCM) approach to the accessory lung lobe and to compare its accessibility with intercostal thoracotomy (ICT) and median sternotomy (MS). Cadaveric study. Twelve canine cadavers. Cadavers underwent an accessory lung lobectomy using an articulating EndoGIA stapler via randomly assigned approach: ICT (n = 4), MS (n = 4) or TDCM (n = 4). The percentage of accessory lung tissue removed was measured in surface area and weight. Exposure was measured as area of cavitary or bicavitary exposure at maximal retraction, by tracing a line around the circumference of the exposed cavity using an imaging software. Staple line leak pressures were evaluated to 40 cmH2O. The average area of exposure was larger in the TDCM approach (TDCM = 193.5 cm2, MS = 106.5 cm2, ICT = 73.5 cm2); (p = .01). Two of four ICT staple lines leaked at 40 cmH2O or lower, and 1/4 MS resulted in iatrogenic damage to an adjacent lobe. There was no difference in the percentage of the lobe excised by weight or surface area between groups. The transdiaphragmatic and caudal median sternotomy approach provided greater exposure, although the percentage of the lobe excised and the surgical time did not differ between approaches. All three approaches allowed for adequate excision of the accessory lung lobe (ALL) with similar surgical times; however, the TDCM approach provided a greater area of exposure, which could increase accessibility to the ALL.

Ventricular assist devices as bridge to heart transplantation: minimally invasive approach with axial pumps vs sternotomy approach with centrifugal pumps: short term results

Abstract Introduction Microaxial flow ventricular assist devices (VADs) with hybrid approach could provide an advantage over centrifugal flow VADs with surgical implantation via median sternotomy as bridge to heart transplantation. Purpose We aimed to compare short-term results in intensive cardiac care unit between both groups. Methods Single-center retrospective registry comparing patients supported with microaxial flow VADs with hybrid approach (Impella 5.0 or 5.5) and surgical centrifugal flow VADs (biventricular or left univentricular CentriMag) as bridge to heart transplantation. Results Including 12 patients (January 2020-March 2022), 7 patients in hybrid approach group (2 patients with Impella 5.0-16,7% and 5 patients with Impella 5.5-41,7%) and 5 pacientes in sternotomy approach group (33.3% biventricular support and 8.3% left ventricular support). In first 48 hours after VAD implantation, worsening of renal function was greater in sternotomy approach group (Cr 2.23±0.88, 1.07±0.58;p=0.021) and there was a trend toward lower hemoglobin values (7.72±0.19, 8.9±1.35;p =0.059), with no differences in other analyzed variables (Table). A trend toward earlier respiratory weaning was observed in hybrid approach group (median 12 vs 48 hours,p=0.067). Sternotomy approach group required more frequent use of continuous renal replacement therapy (60% vs 0%,p=0.045). There were statistically non-significant differences in need for blood products or surgical reinterventions, although percentage of red blood cells transfused in first 48 hours after VAD implantation were lower in hybrid approach group than sternotomy approach group (median 4 (1.5-8) versus 8(2.5-13.5) in sternotomy approach group, p=0.309). The most common complication in sternotomy approach group was tamponade (80%- 4 patients versus 0 patients in hybrid approach) and in hybrid approach group access-related infections (28.57%, 2 patients). Ten patients received a transplant, one died for non-cardiovascular cause, and another underwent the implantation of long term VAD as bridge to transplantation. There were no differences in time from assistance implantation to heart transplantation. The most common complication after heart transplantation was primary graft failure in both groups (40%,2 patients) with no differences in mortality. Conclusions Microxial flow VADs with hybrid approach provide adequate support, with less need for continuous renal replacement therapy and shorter duration of mechanical ventilation after VAD implantation to admission in intensive cardiac care unit, a trend towards lower rates of reintervention due to bleeding was observed. The advantages of minimally invasive approach could increase its use as bridge to heart transplantation compared to VADs with sternotomy approach although small sample size may negatively influence the failure to reach statistical significance, and more studies are necessary to validate our preliminary experience.Variables analyzed 48 hours of admission

Totally 3D endoscopic aortic valve replacement: initial results and experience from a single center.

This study aimed to evaluate the feasibility and initial outcomes of totally endoscopic aortic valve replacement (TEAVR) performed via a single working port at the fourth intercostal space (ICS) utilizing a 3D endoscopic system. A retrospective observational study was conducted on 35 consecutive patients who underwent TEAVR over a six-month period from December 2023 to June 2024. Patient selection was based on the presence of isolated aortic valve disease without the need for ascending aorta replacement or aortic root enlargement. A 4 cm single working port was created at the 4th ICS, extending from the right mid-axillary to the anterior axillary line. A 10-mm trocar for a 3D endoscope was placed at the right anterior-axillary line. Peripheral cardiopulmonary bypass (CPB) was established. The primary outcomes investigated included the success rate of the procedure, in-hospital mortality, and perioperative complications. The mean age of the patients was 58.7 ± 12.8 years, with 22.9% being female. The majority of patients (77.1%) presented with aortic stenosis, often accompanied by severe calcification. The medianCPB time was 210 ± 43 min, and the median aortic cross-clamp time was 132 ± 41 min. The procedure was successfully completed in all patients using the endoscopic approach, with no conversions to full sternotomy. Two mortalities were recorded, attributed to postoperative complications including bleeding and cerebral infarctions. The early (30-day) mortality rate was 5.7%. Prolonged mechanical ventilation (>48 h) was required in 17.1% of patients, and reoperation for bleeding was necessary in 2.9% of patients. TEAVR is a feasible procedure with the potential to replace the traditional sternotomy approach for aortic valve replacement.

Supraclavicular-median sternotomy approach for a large neurilemmoma invading the thoracic outlet: a case report and review of the literature

BackgroundLarge mediastinum tumors invading the thoracic outlet have consistently been a challenge in thoracic surgery. Due to the large size of the tumor and its proximity to many important tissues, appropriate surgical approaches are crucial for a successful surgery.Case presentationsHere, we present a case of a large neurilemmoma that invaded the thoracic outlet that was resected by a supraclavicular-median sternotomy approach. The case was a 58-year-old woman with a large mass in the right chest cavity that had invaded the thoracic outlet. The preoperative biopsy showed a blood clot with a few fibrous connective tissues covered by a single layer of flat epithelium. There was insufficient evidence to diagnose the mass as a tumor, and imaging examinations suggested a diagnosis of solitary pleural fibroma. For good exposure of the cranial and caudal aspects of the large mass, we devised a median sternotomy combined with a supraclavicular approach and safely achieved complete resection. The patient recovered well and experienced no severe complications or functional restrictions of the upper extremity. The postoperative pathology diagnosis was a neurilemmoma.ConclusionsThe supraclavicular-median sternotomy approach could be an optional approach for the complete resection of large mediastinal tumors invading the thoracic outlet.

A Needle's Misdirection: Unravelling Vascular Injuries in Malpositioned Central Venous Catheters and Safe Removal Approaches

Central venous catheters (CVC) are commonly inserted to obtain vascular access. Complications such as vascular injuries arising from malpositioned CVC may occur, and safe surgical removal is required to prevent further complications. We retrospectively reviewed all patients treated in the cardiothoracic surgery department at our institution in the past 10 years for intrathoracic vascular injuries in malpositioned CVC without the need for concurrent cardiac or thoracic surgical procedures. Among the 21 patients in our series, 2 patients (10%) had a single arterial injury, 16 patients (76%) had venous injuries only, and 3 patients (14%) had both arterial and venous injuries. 16 patients (76%) underwent surgery to remove the malpositioned CVC; majority of them underwent sternotomy (n=12, 57%) and 7 of them had repair of blood vessels, and 4 patients (19%) underwent video assisted thoracoscopic surgery (VATS). 2 out of the 5 patients who had their CVC directly removed followed by external compression required emergency sternotomy due to pericardial effusion. In patients with artery or mediastinal vessel injuries, a sternotomy approach was preferred, whereas VATS was chosen when subclavian vessels or brachiocephalic vein injuries were noted. Endovascular procedures are alternatives for high surgical risk patients, but these advanced procedures are currency limited due to high expertise and facilities requirements.

Parasternal thoracotomy via sternocostal disarticulation: a novel surgical approach to the canine thorax.

To describe the technique and outcomes of a modified paramedian thoracic approach in dogs involving a parasternal thoracotomy via rib disarticulation at the sternocostal joint. 93 client-owned dogs. Medical records of dogs that underwent parasternal thoracotomy at a private practice between the years 2015 and 2021 were reviewed. Signalment, weight, clinical presentation, surgical details, complications, and short-term outcomes were recorded. Cox proportional hazards regression models were utilized to analyze the impact of covariates on hazard events. Kaplan-Meier curves were employed to evaluate survival functions for select variables. Parasternal thoracotomy via sternocostal disarticulation was performed in 93 dogs. Eighty-eight dogs (94.6%) survived the procedure. Eighty-three dogs (89.2%) survived to discharge from the hospital. Age, weight, postoperative time to eating, postoperative ambulation, and surgical or anesthetic duration were not significantly associated with survival to discharge. Thoracostomy tube duration significantly decreased the likelihood for survival to discharge; for each additional hour of thoracostomy tube placement, the odds of survival to discharge diminished by 5.7% (hazard ratio, 0.94; 95% CI, 0.912 to 0.976). Parasternal thoracotomy via rib disarticulation at the sternocostal joints may be a viable alternative to median sternotomy that does not require specialized equipment for bilateral hemithoracic visualization. Postoperative complications and short-term outcomes are comparable to those reported for the traditional median sternotomy approach. Prolonged thoracostomy tube duration may impact survival to discharge.

A Clinical Study on the Treatment of Adult Atrial Septal Defect Using Thoracoscopic-Assisted Right Vertical Infra-Axillary Thoracotomy, Total Thoracoscopic, and Median Sternotomy Approaches

Background: To compare the clinical outcomes of three surgical approaches for treating adult atrial septal defects (ASD): Thoracoscopic-assisted right vertical infra-axillary thoracotomy (TARVIAT) under central cardiopulmonary bypass (CPB), totally thoracoscopic (TT), and median sternotomy (MS) approaches, and to assess the feasibility and safety of the TARIAVT approach. Methods: This study reviewed 62 cases patients of repairing atrial septal defects via a TARVIAT and central extracorporeal circulation from 2019 to 2023. The patients included 22 males, aged between 18 and 59 years, with a mean age of 33.35 ± 10.97 years. The surgical indications were adult patients with moderate to severe tricuspid regurgitation and who were unsuitable for interventional closure of atrial septal defects. Exclusion criteria included patients diagnosed with severe pulmonary hypertension or Eisenmenger syndrome. Additionally, 67 patients who underwent TT approach repair of ASD and 72 patients who underwent MS approach repair of ASD were selected as the control groups. Operative time, CPB time, aortic clamping time, postoperative Intensive care unit (ICU) stay, postoperative mechanical ventilation time, 24-hour postoperative chest drainage, incision length, postoperative hospital stay, hospital costs, and postoperative complications were compared to assess statistical differences. Results: There were no deaths or major complications observed in any of the three groups. Statistically significant differences were found among the three groups in terms of extracorporeal circulation time, aortic clamping time, surgical time, 24-hour postoperative chest drainage, postoperative mechanical ventilation time, postoperative ICU stay, incision length, and postoperative hospital stay (p < 0.05). The TT group exhibited longer CPB and aortic clamping times compared to the TARVIAT and MS groups, while demonstrating lower 24-hour postoperative chest drainage volumes compared to the TARIAVT and MS groups. Both the TARVIAT and TT groups showed shorter surgical times, postoperative mechanical ventilation times, postoperative ICU stay, incision lengths, and postoperative hospital. However, there were no statistically significant differences among the three groups regarding hospital costs, postoperative left ventricular ejection fraction (LVEF) values, and the incidence of postoperative complications (p > 0.05). Conclusions: TARVIAT under central CPB is feasible and safe for adult patients. This approach presents lower invasiveness, shorter operative duration, and faster recovery compared to other methods. In conclusion, the TARVIAT approach for repairing adult ASD is both safe and effective, offering a viable surgical option for this condition.

Videothoracoscopy and sternotomy approach for adenoid cystic carcinoma: case video

Videothoracoscopy and sternotomy approach for adenoid cystic carcinoma: case video

THE “SANDWICH” TECHNIQUE IN MITRAL ANNULAR CALCIFICATION

Abstract Objective To assess the feasibility and safety of the “Sandwich” technique in case of massive mitral annular calcification (MAC). MAC is a multifactorial chronic disease and a challenging clinical entity to the surgeon: both respecting and resecting techniques have been developed, in order to prevent eventual annular ruptures. Methods Twelve patients underwent mitral valve replacement (MVR) between January and September 2023, mainly because of steno–insufficiency of the mitral valve, in presence of MAC. Their mean age was 76 ± 4.5, their BMI was 27.2 ± 2.8 and their surgery was mostly elective, except for one urgent active endocarditis; their mean EUROscore II was 8.2 ± 2.9. Results We performed 12 MVR with biological valve, through full sternotomy approach. The cardiopulmonary bypass and aortic cross–clamp time were 195 ± 57 and 155 ± 42 minutes respectively. We perform a double line suture respectful of the annular calcium, in order to reinforce the mitral annulus, before fixing the prosthesis. Surgical stiches on the anterior annulus were ordinarily put; on the posterior annulus, which is usually the most calcified part, a teflon band underneath the calcium was fixed as first, through separate prolene 2–0 U–stitches. Then the usual 2–0 ticron stitches with pledget were put between the posterior annulus and the atrial wall. Both 2–0 prolene and ticron were passed through the prosthesis sewing ring: prolene was placed more externally than ticron. No leakages were found, both intraoperative and postoperative. There were no in–hospital deaths. No strokes, thromboembolic or coronary complications were observed. Conclusions The “Sandwich” technique is reproducible, feasible and safe and it does not imply a long surgical learning curve. It is not a disruptive approach, avoiding annulus failure and it is respectful of the cardiac structures.

Thoracoscopic-assisted, minimally invasive versus off-pump bypass grafting for single vessel coronary artery disease – A propensity matched analysis

ObjectiveThis study compared perioperative outcomes after off-pump revascularization through a thoracoscopic-assisted (non-robotic) minimally invasive approach (Endo-CAB) or sternotomy approach (OPCAB) for patients with single vessel left anterior descending (LAD) disease. MethodsIn this retrospective, propensity matched cohort study, 266 consecutive patients were included in the Endo-CAB group (n = 136) and OPCAB group (n = 130). After propensity score matching 116 Endo-CAB and 116 OPCAB patients were compared. ‘Textbook outcome’ was defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischemia, cardiac tamponade, cerebrovascular events, wound infection, new-onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (> 7 days). Multivariable regression analysis was performed to identify independent predictors for textbook outcome. ResultsTextbook outcome occurred significantly more frequent in the Endo-CAB group compared to the OPCAB group (81.9% vs. 59.5%, p < 0.001). Patients undergoing Endo-CAB surgery had shorter hospital admission (3.0 [3.0–4.0] vs. 5.0 [4.0–6.0] days, p < 0.001), less blood loss (225 [150–355] vs. 450 [350–600] mL, p < 0.001). Other perioperative outcomes were comparable for both groups. Regression analysis demonstrated that Endo-CAB approach was an independent positive predictor for textbook outcome (OR 3.02, 95% CI 1.61–5.66, p < 0.001). ConclusionsOur study suggests that patients undergoing Endo-CAB surgery have improved perioperative outcome resulting in higher rates of textbook outcome for the treatment of single vessel CAD. This technique could be widely available since routine thoracoscopic instruments are used.

Results Of Minimally Invasive Vats Thymectomy In Miastenia Gravis Patients Compared With More Invasive Approaches - 10-Year Experience In A Single Center.

Myasthenia gravis (MG) is an autoimmune, neurologic disease that causes a wide range of symptoms. While the transsternal, transcervical and thoracotomy approaches are accepted as effective, there is still debate regarding the VATS approach. We analyzed our center's surgical experience with thymectomy for myasthenia gravis, comparing the results of patients operated on using VATS and more invasive approaches, over a period of 10 years. A search of the department's surgical database for myasthenia gravis cases between January 2010 and January 2021, revealed a total of 40 cases. Twenty-four patients were included in the final analysis and were distributed into two groups: the VATS procedure group (group A) and the open procedure group (group B). The latter included sternotomy, thoracotomy, transcervical and hemiclamshell approaches. Only radical thymectomies were included. The established outcomes were clinical improvement defined as asymptomatic remission, reduction, or discontinuation of the medication necessary to achieve optimal symptom control. The median follow-up time was 27 months (ranging from 4 to 75 months). Videothoracoscopy radical thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement (reduced symptoms or decreased medication) was observed in 8 cases (66.6%). No change in clinical outcome was noted in 1 patient (8.3%). None of the patients reported worsening symptoms. Open thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement was noted in 6 cases (50%). No change in clinical outcome was observed in 3 patients (25%) whereas 2 of them (16.7%) experienced slightly better symptom control but with a significant increase in medication. One patient (8.3%) described the clinical results as without any significant change. None of the patients reported worsening symptoms. The videotoracoscopic approach in the treatment of myasthenia gravis is non-inferior compared to the open approach and effective in a long-term follow-up, offering all the additional benefits of less invasive surgery.

Isolated or Combined Ascending Aortic Replacement through a Partial Sternotomy: Early and Midterm Outcomes

Abstract Background We aimed to investigate the in-hospital and midterm outcomes of patients undergoing ascending aortic replacement (AAR) through a partial or a full sternotomy approach through a propensity matching analysis. Methods We retrospectively included all patients (n = 167) who underwent elective AAR in our institution between 2013 and 2020. The study population was divided into two groups according to the surgical access (40 patient in the partial sternotomy or “PS” group and 127 in the full sternotomy or “FS” group). Due to the significant differences between the groups, a propensity matching of 1:3 was applied. In-hospital complications, survival, and reoperation at follow-up were investigated. Results The PS group showed higher cross-clamp and cardiopulmonary bypass times than the FS group (94.2 vs. 83 minutes and 164.2 vs. 126.8 minutes, respectively). Moreover, the postoperative ventilation time was significantly higher in the PS group, but it did not affect the length of stay in the intensive care unit (ICU). The incidences of bleeding, stroke, and mortality were comparable between the two groups (11 vs. 3%, 3 vs. 6%, and 5 vs. 3%, respectively). After a median follow-up of 2 ± 1.98 years, the Kaplan–Meier analysis showed no significant differences between the two groups (log-rank, p = 0.17) in terms of survival. Conclusion The surgical ascending aorta replacement through a partial sternotomy is associated with longer operative times, but this does not affect the early as well as the long-term follow-up.

Surgical outcomes of the systemic-to-pulmonary artery shunt: risk factors of post-operative acute events and effectiveness of regulation of pulmonary blood flow with metal clips.

The aim of this study was to analyze the risk factors for acute events after systemic-to-pulmonary shunt (SPS) and to investigate the effectiveness of pulmonary blood flow regulation with a metal clip. The case histories of 116 patients (78 biventricular [BV] and 38 single ventricle [SV] physiology) who underwent SPS between 2010 and 2021 were retrospectively reviewed. Our strategy was to delay SPS until 1month of age; pulmonary blood flow (PBF) regulation by partial clipping of the graft, if needed. Cases of aortic cross-clamping were excluded from this study. CPB was used in 49 (42%) patients: the median age at SPS was 1month (2days to 16years), and the sternotomy approach in 65. Discharge survival was 98.3% (114/116); hospital death occurred in 1.7% due to coronary ischemia. Inter-stage mortality occurred in 1.7% (shunt thrombosis, 1; pneumonia, 1). Pre-discharge acute events occurred in 7 patients (6.0%): thrombosis 3, pulmonary over-circulation 2, and coronary ischemia 2. Multiple logistic regression analysis revealed that pulmonary atresia with intact ventricular septum (PA/IVS) (p = 0.0253) was an independent risk factor for acute events. Partial clipping of the graft was performed in 24 patients (pulmonary atresia 15) and clip removal was performed by catheter intervention in 9 patients; no coronary ischemic events and graft injury occurred in these patients. Surgical outcomes after SPS were acceptable and metal clip regulation of pulmonary blood flow appears to be safe and effective. PA/IVS was still a significant risk factor for acute events.

The roles and outcomes of surgery in large anterior mediastinal tumors

Introduction: Large anterior mediastinal tumors are rare and encompass a wide diversity of neoplasms. The anatomical complexity of large mediastinal tumors poses clinical challenges in term of surgical feasibility, tumor resectability, and disease curability. Due to the rarity of this clinical entity, very few studies have been conducted on large mediastinal tumors. Here, we describe the surgical approach and outcomes of surgery for large mediastinal tumors. Method: A retrospective analysis was conducted on patients with large anterior mediastinal tumors who underwent biopsy and surgical resection at our center from January 2018 to December 2020. Results: A total of 87 patients were referred for anterior mediastinal tumors, and 42 of them (48.3%) had tumors larger than 8 cm. The average age was 36.4 years, with a male-to-female ratio of 4:6. The average tumor size was 13.2 cm. Twenty-six patients (61.9%) underwent surgical biopsy; 16 of them were diagnosed with lymphoma, and another 10 patients had nonlymphoma tumors. Complete surgical resection was performed on 24 patients (57.1%). Surgical biopsies were performed using video-assisted thoracoscopic surgery (61.5 %) and the Chamberlain procedure (38.5%). Surgical resection was performed with median sternotomy (66.7%), thoracotomy (20.8%), and hemiclamshell approach (12.5%). There were no immediate postoperative mortality. Conclusion: This series has shown the clinical feasibility of definitive surgical management for large mediastinal tumors, with positive clinical outcomes. Given the rarity of large mediastinal tumors, detailed preoperative preparation with multimodal imaging and multidisciplinary team discussion are essential for favorable surgical outcomes.

Minimally Invasive Approach versus Sternotomy for Cardiac Surgery in Jehovah's Witness Patients

To evaluate the outcomes of minimally invasive cardiac surgery (MICS) compared with the sternotomy approach for Jehovah's Witness (JW) patients who cannot receive blood transfusions DESIGN: This was a retrospective observational study. The study was conducted at a specialized cardiovascular intervention and surgery institute. The study cohort comprised JW patients undergoing cardiac surgery between September 2016 and July 2022. None MEASUREMENTS AND MAIN RESULTS: Patients (n = 63) were divided into MICS (n = 19) and sternotomy (n = 44) groups, and clinical outcomes were analyzed. There was no difference in types of operation except coronary bypass grafting (n = 1 [5.3%] in the MICS group v n = 20 [45.5%] in the sternotomy group; p = 0.005). There were no between-group differences in early mortality and morbidities. Overall survival did not differ significantly during the follow-up period (mean, 43.9 ± 24.4 months). The amount of chest tube drainage was significantly lower in the MICS group on the first postoperative day (mean, 224.0 ± 122.7 mL v 334.0 ± 187.0 mL in the sternotomy group; p = 0.022). The mean hemoglobin level was significantly higher in the MICS group on the day of operation (11.7 ± 1.3 mg/dL v 10.6 ± 2.0 mg/dL in the sternotomy group; p = 0.042) and the first postoperative day (12.3 ± 1.8 mg/dL v 11.2 ± 1.9 mg/dL; p = 0.032). MICS for JW patients showed favorable early outcomes and mid-term survival compared to conventional sternotomy. MICS may be a viable option for JW patients who decline blood transfusions.

Combined Transcervical and Median Sternotomy Approach for a Massive Substernal Goiter.

Herein, we describe a combined transcervical and median sternotomy approach for a massive substernal goiter causing tracheal stenosis. A goiter of this size, specifically weighing 630g, is rare. We advocate for a multidisciplinary approach for airway management and for consideration of awake fiberoptic intubation with tracheosomy avoidance for similar patients.

Comparative analysis of robotically-assisted versus conventional sternotomy approach in left atrial-myxoma resection: A single-center retrospective observational study

BackgroundMinimally invasive surgery has emerged as a favorable alternative to conventional surgery for various cardiac conditions. This study aimed to compare the perioperative outcomes and follow-up results of the robotic approach versus the sternotomy approach for left atrial myxoma (LAM) resection. MethodWe retrospectively analyzed the perioperative outcomes and follow-up results of 94 patients who underwent left atrial myxoma resection using either the sternotomy approach (n = 64) or the robotic approach (n = 30) at our center between January 2017 and April 2023. Multiple linear regressions were employed to examine the actual impact of the surgical approach on perioperative outcomes while controlling for potential confounding factors. ResultsThere were no in-hospital deaths or follow-up deaths in the robotic group. Univariate analyses revealed that robotic LAM resection had a longer cardiopulmonary bypass (CPB) time (99.93 ± 22.30 vs. 76.28 ± 24.92, P < 0.001), longer aortic clamping time (57.80 ± 20.27 vs. 47.89 ± 18.10, P = 0.019), reduced postoperative drainage (P < 0.001), shorter mechanical ventilation time (P = 0.005), shorter postoperative bed-stay time (P < 0.001), shorter postoperative hospitalization time (P = 0.040), and higher hospital costs (P = 0.001) compared to the sternotomy group. After adjusting for baseline characteristics in a multiple regression model, a longer CPB time (B = 28.328; CI, 18.609–38.047; P < 0.001), longer aortic clamping time (B = 11.856; CI, 4.069–19.644; P = 0.003), reduced postoperative drainage (B = −200.224; CI, −254.962– –145.486; P < 0.001), shorter mechanical ventilation time (B = −3.429; CI, −6.562– –0.295; P = 0.032), shorter postoperative bed-stay time (B = −2.230; CI, −3.267– –1.193; P < 0.001), shorter postoperative hospitalization time (B = −1.998; CI, −3.747– –0.250; P = 0.026), and higher hospital costs (B = 2096.866, P = 0.002) were found in the robotic group. Furthermore, the robotic group exhibited a faster return to exercise compared to the sternotomy group (Log-Rank χ2 = 34.527, P < 0.001). ConclusionBoth the robotic and sternotomy approaches are viable and safe options for LAM resection. However, despite the higher costs, longer CPB time, and longer aortic clamping time associated with robotic LAM resection, this technique was correlated with reduced postoperative drainage and faster postoperative recovery compared to the sternotomy technique.

Are the minimally invasive techniques the new gold standard in thymus surgery for myasthenia gravis? Experience of a reference single-site in VATS thymectomy.

The thymus is the primary lymphoid organ responsible for the maturation and proliferation of T lymphocytes. During the first years of our lives, the activation and inactivation of T lymphocytes occur within the thymus, facilitating the correct maturation of central immunity. Alterations in the positive and negative selection of T lymphocytes have been studied as the possible origins of autoimmune diseases, with Myasthenia Gravis (MG) being the most representative example. Structural alterations in the thymus appear to be involved in the initial autoimmune response observed in MG, leading to the consideration of thymectomy as part of the treatment for the disease. However, the role of thymectomy in MG has been a subject of controversy for many years. Several publications raised doubts about the lack of evidence justifying thymectomy's role in MG until 2016 when a randomized study comparing thymectomy via sternotomy plus prednisone versus prednisone alone was published in the New England Journal of Medicine (NEJM). The results clearly favored the group of patients who underwent surgery, showing improvements in symptoms, reduced corticosteroid requirements, and fewer recurrences over 3 years of follow-up. In recent years, the emergence of less invasive surgical techniques has made video-assisted or robotic-assisted thoracoscopic (VATS/RATS) thymectomy more common, replacing the traditional sternotomy approach. Despite the increasing use of VATS, it has not been validated as a technique with lower morbidity compared to sternotomy in the treatment of MG. The results of the 2016 trial highlighted the benefits of thymectomy, but all the patients underwent surgery via sternotomy. Our hypothesis is that VATS thymectomy is a technique with lower morbidity, reduced postoperative pain, and shorter postoperative hospital stays than sternotomy. Additionally, VATS offers better clinical improvement in patients with MG. The primary objective of this study is to validate the VATS technique as the preferred approach for thymectomy. Furthermore, we aim to analyze the impact of VATS thymectomy on symptoms and corticosteroid dosage in patients with MG, identifying factors that may predict a better response to surgery.

Thirteen Years of Impactful, Minimally Invasive Coronary Surgery: Short- and Long-Term Results for Single and Multi-Vessel Disease

Objectives: Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases. Methods: A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints. Results: A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4). Conclusions: Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

Tailored surgical strategies for mini-access open total arch repair

ObjectiveOpen arch repair is perceived as a challenging, high-risk procedure, with a barrier against the use of a minimally invasive approach. We aimed to present a mini-access total arch replacement performed by stratified approaches and to evaluate perioperative outcomes to contribute to the body of evidence. MethodsWe evaluated 40 consecutive patients (aged 69.5 years; interquartile range, 65.6-76.3 years) undergoing elective total arch replacement using 5- to 8-cm upper mini-sternotomy between 2018 and 2022. Surgical strategies, including arterial inflow site and methods of branching vessel reconstruction, were systematically selected at the individual level. To evaluate comparative outcomes, contemporary cases undergoing total arch replacement via sternotomy with similar eligibility criteria served as a control group, and the inverse-treatment-weighting method was used to adjust for baseline characteristics. ResultsArch-first anastomosis using trifurcate graft, distal-first anastomosis using 4-branch graft, and island anastomosis were used in 18 (45%), 12 (30.0%), and 10 (25%) patients, respectively. Lower body and cardiac ischemic times were 23.4 minutes (interquartile range, 18.0-29.0 minutes) and 66.7 minutes (interquartile range, 50.1-78.2 minutes). There was no early (30-day or in-hospital) mortality, and 2 patients experienced disabling stroke (5.0%). The contemporary control group comprised 55 patients. After an adjustment, a mini-access group showed lower risks of stroke (odds ratio, 0.88; 95% CI, 0.78-1.00; P = .049) and a composite of major complications (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .003), compared with a sternotomy approach. ConclusionsBased on present results, mini-access total arch replacement may be performed with reasonable safety and efficiency.