Sternotomy Conversion Research Articles

Transapical beating heart septal myectomy learning curve and training of future surgeons: an observational study

Background: Description of the learning curve for transapical beating heart septal myectomy (TA-BSM) helps to understand the potential for wider adaptability. We elaborate and examine a competency-based training assessment for TA-BSM that could serve to disseminate septal myectomy expertise. Materials and Methods: Data on 177 consecutive patients who underwent the TA-BSM for hypertrophic obstructive cardiomyopathy (HOCM) between April 2022 and June 2023 was collected prospectively, which was registered on ClinicalTrials.gov. Using the cumulative sum analysis, we identified 2 distinct learning phases based on the procedural time. Outcomes of procedural success and major complications were also compared between phases. Assessment through a Likert scale competency-based assessment of a myectomy surgeon after on-site TA-BSM training. Results: The cumulative sum analysis of procedural time showed 2 well-differentiated phases: the initial phase (cases 1-44) and the proficiency phase (cases 45-177). After 44 cases, significant improvements in procedural time were observed (113 vs. 134 min; P<0.001). Optimal procedural success (left ventricular outflow tract gradient <30 mm Hg and mitral regurgitation grade ≤1+ without mortality or median sternotomy conversion) increased in the proficiency phase (93.2% vs. 79.5%; P=0.018), while complications decreased. The assessment of another surgeon showed consistent agreement in operative decision-making and performance for all evaluated domains. Conclusions: Competence in TA-BSM was achieved after 44 cases, without sacrificing guideline-desired outcomes. Appropriate training of other septal myectomy surgeons could further expedite this learning curve. This new technique may represent an option for wider dissemination of HOCM surgery worldwide and improve disease management.

Outcomes of minimally invasive isolated tricuspid valve reoperation after left-side valve surgery: A single-center experience.

Late severe tricuspid regurgitation (TR) after left-side valve surgery (LSVS) is not uncommon. However, the tricuspid valve has been deemed the forgotten valve because the isolated TR is well tolerated with medication, and reoperation has a higher rate of adverse events. With the advancement of minimally invasive techniques, isolated tricuspid valve reoperation (ITVR) via totally endoscopy or transcatheter approach brings the tricuspid valve into spotlight. Our aim is to report the safety and efficacy of minimally invasive ITVR using endoscopic and transcatheter approaches. From October 2020 to October 2021, 21 patients with LSVS history and secondary massive TR underwent minimally invasive ITVR in our institution. Baseline characteristics, surgical outcomes and follow-up results were analyzed, and data between the totally endoscopy approach and the transcatheter approach were compared. Of the 21 cases, totally endoscopic isolated tricuspid valve surgery (EITVS) accounts for 16 (76.2%) cases, with 14 tricuspid valvuloplasty cases, and 2 tricuspid valve replacement cases; the remaining 5 (23.8%) cases underwent transcatheter tricuspid valve replacement (TTVR). The mean age was (60.0 ± 8.4) years, with 15 (71.4%) being female. Minimally invasive ITVR procedures were 100% successfully performed in all patients without any perioperative mortality, sternotomy conversion, or reoperation. During the median follow-up of 16.8 months (IQR, 13.0-20.6 months), New York Heart Association Class improved significantly from baseline (P = 0.004). TR severity was significantly improved during postoperative and follow-up period (both P < 0.001). Compared with the EITVS group, the TTVR group had a higher clinical risk score [8.00 (8.00, 9.00) vs. 5.00 (3.25, 5.00), P = 0.001], but a higher success rate in reducing TR to less than grade 1+ (100 vs. 43.8%, P = 0.045) at follow-up. In our series, minimally invasive ITVR, including EITVS and TTVR, is a safe and feasible option for severe TR after LSVS, and presents excellent early outcomes in selected patients. TTVR is a reliable alternative for patients with high surgical risk. To improve the results of ITVR, it is necessary to improve patient's preoperative status or perform reoperation before the onset of significant right heart failure. Further studies with a larger sample size and a longer follow-up period are awaited.

Surgical Outcomes of Cardiac Myxoma Resection Through Right Mini-Thoracotomy.

With recent advances in cardiac surgery through minimal access, mini-thoracotomy has emerged as an excellent alternative for cardiac myxoma resection. This study analyzed the surgical results of this approach, focusing on postoperative cerebral embolism and tumor recurrence. We retrospectively reviewed 64 patients (mean age, 56.0±12.1 years; 40 women) who underwent myxoma resection through mini-thoracotomy from October 2008 to July 2020. We conducted femoral cannulation and antegrade cardioplegic arrest in all patients. Patient characteristics and perioperative data, including brain diffusion-weighted magnetic resonance imaging (DWI) findings, were collected. Medium-term echocardiographic follow-up was performed. Thirteen patients (20.3%) had a history of preoperative stroke, and 7 (11.7%) had dyspnea with New York Heart Association functional class III or IV. Sixty-one cases (95.3%) had myxomas in the left atrium. The mean cardiopulmonary bypass and cardiac ischemic times were 69.0±28.6 and 34.1±15.0 minutes, respectively. Sternotomy conversion was not performed in any case, and 50 patients (78.1%) were extubated in the operating room. No early mortality or postoperative clinical stroke occurred. Postoperative DWI was performed in 32 (53%) patients, and 7 (22%) showed silent cerebral embolisms. One patient underwent reoperation for tumor recurrence during the study period; in that patient, a genetic study confirmed the Carney complex. Mini-thoracotomy for cardiac myxoma resection showed acceptable clinical and neurological outcomes. In the medium-term echocardiographic follow-up, reliable resection was proven, with few recurrences. This approach is a promising alternative for cardiac myxoma resection.

Robotic Off-Pump Totally Endoscopic Coronary Artery Bypass in Patients With Low Ejection Fraction.

Objective: Robotic totally endoscopic coronary bypass (R-TECAB) has been shown to be a safe and effective technique with excellent outcomes. The aim of this study is to assess the feasibility of R-TECAB in patients with low left ventricular ejection fraction (LVEF) and to report our midterm outcomes with up to 7-year follow-up. Methods: All patients undergoing R-TECAB at our institution between July 2013 and July 2020 were retrospectively reviewed. A total of 100 patients were identified with low LVEF defined as ≤40%. The preoperative characteristics, perioperative and postoperative outcomes, as well as the midterm results were reviewed. Results: The mean LVEF was 31%, and 62% of all patients had preexisting congestive heart failure. Of the cohort, 59% had 3-vessel disease and 6% underwent previous cardiac surgery. Multivessel TECAB was performed in 54%. Hybrid coronary revascularization occurred in 36 individuals. Two patients required cardiopulmonary bypass, and 35% were extubated in the operating room. No sternotomy conversions were required. One patient underwent reoperation for bleeding. No perioperative stroke, myocardial infarction, or mortality occurred. The left internal mammary artery graft patency was 97% at a mean of 1.6 months in the staged hybrid percutaneous coronary intervention group. At midterm follow-up the cardiac-related mortality was 5%. Heart transplant or left ventricular assist device was required in 4 patients, and 1 patient experienced a myocardial infarction. Freedom from major adverse cardiac events was 89%. Conclusions: Off-pump TECAB can be successfully performed in patients with low LVEF in the setting of an experienced and dedicated robotic cardiac surgery team. Our data demonstrate the feasibility of the technique with excellent perioperative and midterm outcomes.

LIVE procedure for ischemic heart failure: the evolution of an unique technique

Abstract Background Ischemic cardiomyopathy is the leading cause of heart failure. In patients with left ventricular (LV) dilatation, low ejection fraction, and transmural scar in an anteroseptal distribution, surgical ventricular reconstruction (SVR) is a treatment option. However, SVR is an invasive procedure which often cannot be offered to patients with ischemic cardiomyopathy due to other comorbidities. Less Invasive Ventricular Enhancement (LIVE) technique is a unique intervention to exclude scarred myocardium, improving symptoms and quality of life. Methods LIVE procedure has evolved from open sternotomy to a hybrid procedure done with right internal jugular vein access and a left minithoracotomy. LV shape and size is restored without extracorporeal circulation by plication of the scarred myocardium. This is achieved by implantation of a series of internal and external microanchors brought together over a poly-ether-ether-ketone (PEEK) tether to make a longitudinal approximation between the LV free wall and the anterior septum. Internal anchors are deployed by a transcatheter technique, through the right internal jugular vein, on the right side of the ventricular septum. Results Between July 2018 and January 2020, 47 patients (84.4% men; mean age 61±12.5 years) were submitted to the LIVE procedure in 16 Institutions in Europe, North America and Asia. Procedural success was 100%. There was no intra-hospital mortality. A mean of 2.3 anchor pairs (median 2) were used to reshape the LV. Echocardiographic data showed an increase in LV ejection fraction (EF) from 31.4±9.2% to 40.0±12.4% (change +29.8%, p&amp;lt;0.001) and LV end-systolic volume index (LVESVI) reduction from 66.6±29.3 ml/m2 to 40.7±21.5 ml/m2 (change −38%, p&amp;lt;0.001) and LV end-diastolic volume index (LVEDVI) reduction from 92.8±39.2 ml/m2 to 60.6±25.9 ml/m2 (change −33.2%, p=0.001) after the procedure. Sternotomy conversion was needed in one patient due to right ventricular perforation. New onset tricuspid valve regurgitation was observed in one patient. There was no case of ventricular septal defect. In the mean follow-up period of 9.8 months, NYHA class improved a median of 1 grade and there was no late mortality. Conclusion Hybrid LV reshaping and volume reduction has proven to be a useful option for patients with symptomatic heart failure after left anterior descending territory myocardial infarction. These results from the latest iteration of the technique show that this approach is safe and has a significant short and mid-term impact on improving EF and reduction in LV. LIVE procedure Funding Acknowledgement Type of funding source: None

Reasons for Conversion and Adverse Intraoperative Events in Robotically Enhanced Minimally Invasive Coronary Artery Revascularization.

The transition from sternotomy access to minimally invasive coronary artery bypass grafting is associated with steep learning curves. This study reports the reasons for sternotomy conversions from robotically enhanced minimally invasive direct coronary artery bypass grafting (RE-MIDCAB) and describes potential risk reduction strategies. The perioperative data of 759 RE-MIDCAB patients (mean age 65.9 ± 10 years, 25.5% female, 30.2% multivessel disease) operated between July 1, 2002 and November 30, 2018 were reviewed for the reasons of conversion and adverse intraoperative events. Hybrid revascularization was planned in 204 (26.9%) patients. Sternotomy conversion occurred in 30 (4.0%) patients. Lung adhesions and unsuccessful single-lung ventilation prohibited safe RE-MIDCAB internal thoracic artery (ITA) harvesting in 11 (36.7%) and 1 (3.3%) patients, respectively. ITA dysfunction (n = 11, 36.7%) and inadequate target vessel visualization (n = 3, 10.0%) were among the anatomical reasons for conversions. Adverse intraoperative events included ventricle perforation (n = 1, 3.3%) and sustained ventricular arrhythmia (n = 1, 3.3%). The in-hospital mortality and mean length of hospitalization for sternotomy conversion were 3.3% (n = 1 of 30) and 13.4 ± 14.5 days, respectively. Perioperative morbidities included pneumonia (n = 4, 13.3%). Premorbid renal dysfunction predicted sternotomy conversion at the 5% level of significance. RE-MIDCAB provides an attractive surgical platform for primary- or hybrid coronary artery procedures. The progressive increase in patient risk profiles, strict quality control, and focus on clinical governance require awareness of reasons that potentially contribute RE-MIDCAB to sternotomy conversion to ensure safe and sustainable programs.

Totally endoscopic mitral valve repair using a three-dimensional endoscope system: initial clinical experience in Korea.

BackgroundThe lack of depth perception is a significant challenge in two-dimensional (2D) video-assisted/directed minimally invasive cardiac surgery (MICS). Accordingly, restoration of stereoscopic vision is potentially beneficial, and we present a single center experience of a three-dimensional (3D) endoscope system in cardiac surgery without robotic assistance.MethodsWe retrospectively reviewed the initial 40 consecutive patients who received totally endoscopic mitral valve (MV) repair using a 3D endoscope system between September 2017 and April 2019. The preoperative characteristics, operative data, and immediate postoperative outcomes, including echocardiographic results, were investigated.ResultsIn all the patients (n=40, 100%), successful MV repair using the standard repair techniques was achieved regardless of the location of the MV lesion as follows: anterior leaflet (n=8, 20.0%), posterior leaflet (n=15, 37.5%), and both leaflets (n=17, 42.5%). Concomitant tricuspid ring annuloplasty (n=9, 22.5%) and atrial fibrillation ablation (n=7, 17.5%) were performed. There was no mortality. One reoperation for bleeding occurred. One patient had a sternotomy conversion due to aortic dissection immediately after declamping. Postoperative mitral regurgitation (MR) grades were none or trace in 38 patients (95.0%) and mild in 2 patients (5.0%) on predischarge echocardiography.ConclusionsTotally endoscopic MV repair using a 3D endoscope system is technically feasible and safe on the basis of this initial experience.

Minithoracotomy and Beating Heart Strategy for Mitral Surgery in Secondary Mitral Regurgitation.

In patients with secondary mitral regurgitation (MR) associated with low ejection fraction or previous heart surgery, minimally invasive mitral valve surgery without aortic cross-clamp (MIMVS-WAC) has shown promising results. We report our experience for this strategy in our centers. Between August 2011 and April 2017, 46 patients (mean age 69 ± 11 years, 76% males) received MIMVS-WAC. Indications for this technique were prior coronary bypass surgery (26%), severe or recent left ventricular (LV) dysfunction (30%), or both (39%). The mean EuroSCORE II was 12 ± 10. For each procedure, we conducted right minithoracotomy and hypothermic cardiopulmonary bypass (CPB) after peripheral cannulation. Mean CPB time was 159 ± 39 minutes. A mitral valve replacement (MVR) was performed in 23 cases (50%), an annuloplasty in 22 cases (48%), and a prosthesis pannus removal in 1 case (2%). Mean hospital length of stay was 12 ± 5.4 days. We report no sternotomy conversions, six reoperations for bleeding, and three deaths at 30 days. Transfusion was requested in 62% (mean infusion 2 ± 2.4 packed red blood cells). The postoperative echocardiography showed an LV function preservation in 69% of cases and a reduction of pulmonary arterial pressure in 73% of cases. Four additional deaths occurred in the long-term follow-up (mean 637 ± 381 days, median 593 days). No mitral reoperation was required, with a MR ≤ 2 in 90% of patients. In high-risk patients, the MIMVS-WAC is a safe technique. It avoids hard dissections while ensuring excellent preservation of cardiac function.

Complications and pitfalls in minimally invasive atrioventricular valve surgery utilizing endo-aortic balloon occlusion technology

Background: This studyreports the intra-operative complications, reasons for sternotomy conversion(SC) and the important pitfalls associated with minimally invasiveatrioventricular valve surgery by endo-aortic balloon occlusion (MIAS) that mayassist emerging centres in developing safe, efficient and sustainable programs. Methods: Peri-operative data for patientsoperated over the last 5 years was obtained from a prospective database. Intotal, 511 consecutive patients with isolated atrioventricular valve (AVV)disease underwent MIAS (mean age 65.6±13.7 years, 46.8% female, 21.7% redo-cardiacsurgery, 5.7% previous MIAS, 2.9% isolated AVV endocarditis, 13.9% body massindex above 30 kg/m 2 ) at our institution between May 1 st 2013 and April 30 th 2018. The mean EuroSCORE II was 5.9%±9.4% andrheumatic AVV disease was diagnosed in 32 (6.3%) patients. Other surgicalindications included chronic atrial fibrillation (n=142, 27.8%) and leftventricle outflow tract (LVOT) obstruction in conjunction with mitral (MV) ortricuspid valve (TV) disease (n=7, 1.4%). Results: Procedures performed included 122 AVVreplacements (MV =105, TV =17) and 478 AVV repairs (MV=383, TV=95) in isolationor combination. Concomitant procedures included cryo-ablation (n=142, 27.8%)and LVOT resection (n=7, 1.4%). Intra-operative complications that required SCoccurred in 16 (3.1%) patients and in 13 of 399 (3.3%) isolated MV procedures.Reasons for SC included lung adhesions (n=5, 1.0%), cannulation difficulty(n=3, 0.6%), atrioventricular dehiscence (n=1, 0.2%) and bleeding (n=4, 0.8%).Other peri-operative complications included neurological deficit (n=2, 0.4%)and myocardial infarction (n=1, 0.2%). The intra-operative and 30-day mortalityfor the 5-year MIAS series (n=511) was 0.4% (n=2) and 4.5% (n=23) respectively.Complications that resulted in SC (n=16) were associated with a 25% (n=4)30-day mortality. Conclusions: Minimallyinvasive surgical approaches for AVV disease are increasingly being recognizedas the “gold-standard” in the context of rapidly expanding trans-catheter technologyand increasing patient expectations. In an era of strict quality control andclinical governance, emerging MIAS centres need to be aware of the possibleintra-operative complications and potential pitfalls to apply effective riskreduction strategies that encourage safe and sustainable programs.

OC70 SURGICAL TRANSCATHETER VALVE REPLACEMENT: BOLOGNA'S EXPERIENCE

Abstract Background: Transcatheter valve replacement (TVR) has become an effective solution for high risk patients, especially for those with valve prosthesis dysfunction.We report our ten year experience with early and late results. Methods: From November 2008 to May 2018,131 patients underwent surgical TVR in our center.All patients have been preoperatevely evaluated by the Heart team.Main comorbidities were: peripheral vascular disease in 51.1%, renal failure in 42% and pulmonary disease in 26%.There were 24.4% porcelain aorta and 27.5% of redo.Different prosthesis have been used: Medtronic Corevalve, Edwards Sapien, Jenavalve and Acurate symetis.There were 113 aortic, 15 mitral, 3 tricuspidalic valve disease treated respectively.Main surgical accesses were transapical in 93, transaortic in 31, left subclavian in 5 and full sternotomy in 2 patients. Results: Mean age was 81.1 ± 7.1, mean Euroscore was 9.9 ± 2.2 and STS score was 6.7 ± 5.4%.Overall early mortality was 6.1%.The global experience was divided into three periods as follow 2008–2012, 2013–2015 and 2016–2018 with a mortality rate of 10.4%, 7.3%, and 0% respectively.The only risk-factor for mortality was full sternotomy conversion (p = 0.001; OR = 60.5; CI[4.5;671.6]), necessary in 4 patients.The mean follow up time was 23.96 ± 26.28 months. Overall survival at 1 year, 3 years and 5 years was 84.2%, 61% and 41.6% respectively.Preoperative renal failure was risk factor for mortality at follow-up(p = 0.026;HR = 2.02;CI[1.09;3.75]). Conclusions: Surgical TVR confirmed to be an effective solution for high risk patients, with satisfactory results in terms of mortality and postoperative outcome. With the increase in experience, mortality rate progressively decreased.

Endoscopic Port AccessTM left ventricle outflow tract resection and atrioventricular valve surgery

The continuous evolution in robotic-, endoscopic- and trans-catheter cardiac interventions resulted in innovative techniques that simultaneously address left ventricular outflow tract obstruction (LVOTO) and concomitant atrioventricular valve (AVV) pathology in the context of hypertrophic obstructive cardiomyopathy (HOCM). We present our brief report of 13 consecutive HOCM patients with concomitant AVV disease, who underwent endoscopic left ventricular septal myomectomy (LVSM) and AVV surgery by Endoscopic Port AccessTM Surgery (EPAS) between March 1st 2010 and October 31st 2015. Our EPAS technique in the context of HOCM utilizes peripheral cardiopulmonary bypass, endo-aortic balloon occlusion and a 4-cm right antero-lateral thoracic working port. Access to the LVOTO is obtained by detaching the anterior mitral valve (MV) leaflet from the annulus. Controlled sharp LVSM is then performed from the aortic leaflet base to the papillary muscles. Subsequent routine AVV surgery is performed using long shafted instruments. There were no sternotomy conversions, LVSM complications or 30-day mortalities. The mean length of hospitalization was 17.7±18.1 days. Long-term clinical and echocardiographic analysis of 645.7 patient-months (n=13, 100.0% complete) identified two late mortalities, which were not procedure-, HOCM- or AVV-related. All patients (n=13, 100.0%), including the late mortalities, had significant improvement in their quality of life, a 100% long-term freedom from re-intervention and no residual peak instantaneous LVOTO gradients more than 15 mmHg. This brief report emphasises that simultaneous LVSM and concomitant AVV surgery by EPAS can safely be performed in experienced centres with favourable long-term outcomes.

Endoscopic port access surgery for isolated atrioventricular valve endocarditis.

Our goal was to report the clinical and echocardiographic outcomes of endoscopic port access surgery for isolated active and convalescent atrioventricular valve endocarditis (AVVE). Our current surgical team performed endoscopic port access surgery in 66 consecutive patients with isolated AVVE (mean age, 65.5 ± 12.7 years, 37.9% women, mean EuroSCORE II 31.2 ± 24.9%, 45.5% prosthetic AVVE, Staphylococcus aureus 22.2%), between 1 May 2004 and 31 July 2015. Isolated mitral valve endocarditis was present in 53 (80.4%) patients, including 11 (16.7%) with periannular abscesses. Procedures performed included mitral valve repair (n = 15, 22.7%) and left ventricular septal myomectomy (n = 1, 1.5%). Reasons for sternotomy conversion (n = 6, 9.1%) included lung adhesions (n = 3, 4.5%). The mean cardiopulmonary bypass and ischaemic times were 167.2 ±48.7 and 112.6 ± 33.3 min, respectively. In-hospital morbidities included revision for bleeding (n = 6, 9.1%). The 30-day survival rate was 87.9%. Causes of in-hospital deaths (n = 12) included low cardiac output syndrome (n = 3, 4.5%). Age, critical preoperative status and EuroSCORE II score predicted deaths individually at the 5% level of significance. The Kaplan-Meier analyses (mean 63.2 ± 42.5 months) for survival and freedom from AVVE reintervention at 10 years were 69.4% and 98.4%, respectively. Of the mid-term survivors (n = 50, 93.9% complete), 94.0% (n = 47) classified as New York Heart Association (NYHA) II or less with no mitral valve regurgitation greater than Grade I. Complex atrioventricular valve surgery in the context of AVVE can be endoscopically performed in experienced centres and should not deter surgeons from offering patients with AVVE the potential benefits of minimally invasive cardiac surgery.

Reasons for conversion and adverse intraoperative events in Endoscopic Port Access™ atrioventricular valve surgery and minimally invasive aortic valve surgery.

This study reports the factors that contribute to sternotomy conversions (SCs) and adverse intraoperative events in minimally invasive aortic valve surgery (MI-AVS) and minimally invasive Endoscopic Port Access™ atrioventricular valve surgery (MI-PAS). In total, 3780 consecutive patients with either aortic valve disease or atrioventricular valve disease underwent minimally invasive valve surgery (MIVS) at our institution between 1 February 1997 and 31 March 2016. MI-AVS was performed in 908 patients (mean age 69.2 ± 11.3 years, 45.2% women, 6.2% redo cardiac surgery) and MI-PAS in 2872 patients (mean age 64.1 ± 13.3 years, 46.7% women, 12.2% redo cardiac surgery). A cumulative total of 4415 MIVS procedures (MI-AVS = 908, MI-PAS = 3507) included 1537 valve replacements (MI-AVS = 896, MI-PAS = 641) and 2878 isolated or combined valve repairs (MI-AVS = 12, MI-PAS = 2866). SC was required in 3.0% (n = 114 of 3780) of MIVS patients, which occurred in 3.1% (n = 28 of 908) of MI-AVS patients and 3.0% (n = 86 of 2872) of MI-PAS patients, respectively. Reasons for SC in MI-AVS included inadequate visualization (n = 4, 0.4%) and arterial cannulation difficulty (n = 7, 0.8%). For MI-PAS, SC was required in 54 (2.5%) isolated mitral valve procedures (n = 2183). Factors that contributed to SC in MI-PAS included lung adhesions (n = 35, 1.2%), inadequate visualization (n = 2, 0.1%), ventricular bleeding (n = 3, 0.1%) and atrioventricular dehiscence (n = 5, 0.2%). Neurological deficit occurred in 1 (0.1%) and 3 (3.5%) MI-AVS and MI-PAS conversions, respectively. No operative or 30-day mortalities were observed in MI-AVS conversions (n = 28). The 30-day mortality associated with SC in MI-PAS (n = 86) was 10.5% (n = 9). MIVS is increasingly being recognized as the 'gold-standard' for surgical valve interventions in the context of rapidly expanding catheter-based technology and increasing patient expectations. Surgeons need to be aware of factors that contribute to SC and adverse intraoperative outcomes to ensure that patients enjoy the maximum potential benefit of MIVS and to apply effective risk reduction strategies that encourage safer and sustainable MIVS programmes.

Predictors and Outcomes of Sternotomy Conversion and Cardiopulmonary Bypass Assistance in Minimally Invasive Coronary Artery Bypass Grafting.

This work's objective was to identify the determinants of conversion of minimally invasive coronary artery bypass grafting to sternotomy, with and without cardiopulmonary bypass assistance, and to compare clinical outcomes in patients who needed conversion. This is a prospectively collected data on patients who underwent minimally invasive coronary bypass done by a single surgeon from February 2005 to September 2014. Statistical analyses were expressed as mean values ± standard deviation or proportions. The total number of patients was 266, with an average age of 62 years. The median number of grafted territories was 2, higher in those with pump assistance (median, 3 grafts; P ≤ 0.01). Predictors for use of cardiopulmonary bypass included diabetes, 3-vessel disease, left circumflex involvement, and small target vessels (P < 0.05). The rate for sternotomy conversion was 3.8%. Risk factors for conversion to sternotomy included smoking, preoperative bradycardia (<50 beats per minute), low intraoperative ejection fraction, inability to tolerate one-lung ventilation, inadequate surgical exposure, and hemodynamic instability. Postoperative complications included superficial thoracotomy infection (3%), sternotomy infection (10%), new atrial fibrillation (3%), and need for blood transfusion (14%). Twelve patients (5%) developed left-sided pleural effusion that required drainage. There were no perioperative deaths, major adverse cardiac event, or stroke. Minimally invasive coronary bypass grafting with conversion to sternotomy and use of cardiopulmonary bypass is safe. Conversions may be alleviated by an effort to optimize modifiable risk factors and the adequacy of surgical exposure. These data may help develop objective selection criteria to identify patients who are excellent candidates for the procedure.

Predictors and Outcomes of Sternotomy Conversion and Cardiopulmonary Bypass Assistance in Minimally Invasive Coronary Artery Bypass Grafting

Predictors and Outcomes of Sternotomy Conversion and Cardiopulmonary Bypass Assistance in Minimally Invasive Coronary Artery Bypass Grafting

Endoscopic atrioventricular valve surgery in adults with difficult-to-access uncorrected congenital chest wall deformities.

This study presents the first report on in-hospital and long-term outcomes of endoscopic port access atrioventricular valve surgery (EPAAVVS) in adult patients with uncorrected congenital chest wall deformities (CCWDs). Our current surgical team performed EPAAVVS in 7 consecutive adult patients (mean age 51.3 ± 16.4 years, 14.3% female, 50% older than 60 years, mean EuroSCORE II 0.8 ± 0.1%) with uncorrected CCWDs between 1 November 2009 and 30 November 2015. The mean left ventricular ejection fraction was 66.0 ± 8.5%. Surgical indications included isolated or combined symptomatic mitral valve (MV) regurgitation (n = 7, 100%), left ventricular outflow tract (LVOT) obstruction (n = 1, 14.3%) and patent foramen ovale (n = 3, 42.9%). Fibro-elastic deficiency accounted for 57.1% of MV pathology and 5 patients (74.1%) presented with New York Heart Association (NYHA) Class III symptoms. CCWDs included isolated pectus excavatum (n = 5, 71.4%) and mixed pectus excavatum and carinatum (n = 2, 28.6%). The mean Haller-index and correction index scores were 2.7 ± 0.5 and 21.4 ± 10.2%, respectively. Procedures performed included MV repair (n = 7, 100%), tricuspid valve (TV) repair (n = 1, 14.3%) and left ventricular septal myomectomy (n = 1, 14.3%). There were no sternotomy conversions or complications with chest wall entry or atrioventricular valve exposure. The mean cardiopulmonary bypass and cross-clamp times were 162.1 ± 48.1 and 113.7 ± 33.5 min, respectively. No patient required mechanical ventilation or intensive care treatment longer than 24 h. There were no surgical revisions, in-hospital respiratory or chest wall morbidities. The mean length of hospital stay was 7.4 ± 1.0 days. A total of 208 patient-months (mean 29.7 ± 26.5) were available for long-term clinical and echocardiographic analysis. There were no 30-day or long-term mortalities and no patient required reintervention for residual atrioventricular valve pathology. All patients were classified as NYHA I during recent consultations, and echocardiographic follow-up confirmed no residual MV regurgitation greater than Grade 1 in any patient. EPAAVVS in adults with uncorrected CCWD is safe, feasible and durable and can successfully be performed by experienced teams to achieve Haller index and correction index scores of up to 3.3 and 38.3%, respectively, with favourable long-term clinical and echocardiographic outcomes. The mere presence of uncorrected CCWDs should not deter surgeons from offering these patients the full benefits of minimally invasive cardiac surgery.

Late redo-port access surgery after port access surgery.

This study presents the first report on short- and long-term outcomes in redo-port access surgery after previous port access surgery (redo-PAS-PAS) for new or recurrent mitral valve (MV) and tricuspid valve (TV) disease. Our current surgical team performed redo-PAS-PAS in 26 consecutive patients who had previous port access surgery (mean age 65.8 ± 13.3 years, 46.2% female, 42.3% older than 70 years, mean logistical EuroSCORE 22.5 ± 21.6%) between 1 February 1997 and 30 June 2014. Surgical indications included among others MV prosthesis dysfunction (n = 8, 30.8%), endocarditis (n = 10, 38.5%) and TV dysfunction (n = 3, 11.5%). The mean time interval between primary PAS and redo-PAS-PAS was 70.32 ± 57.4 months. Redo-PAS-PAS procedures included MV replacement (n = 19, 73.1%), MV repair (n = 5, 19.2%), and TV repair (n = 2, 7.7%). Sternotomy conversion was required in 5 patients (19.2%), of which 4 (15.4%) were early conversions due to lung adhesion and 1 (3.8%) due to a late intraoperative complication. The mean cardiopulmonary bypass and cross-clamp times were 163.3 ± 57.9 and 101.2 ± 43.8 min, respectively. Postoperative mechanical ventilation longer than 72 h was required in 4 patients (15.4%). In-hospital morbidities included hospital-acquired pneumonia (n = 3, 11.5%), postoperative air leaks (n = 2, 7.7%) and revision for bleeding (n = 1, 3.8%). The mean length of hospital stay was 16.1 days. Long-term clinical and echocardiographic follow-up were 48.3 ± 39.2 and 44.6 ± 32.9 months, respectively. The Kaplan-Meier analyses for survival and freedom from mitral and tricuspid valve reintervention (n = 26) at 5 years were 83.9 and 95.8%, respectively, with 91.3% of surviving patients classified as being NYHA II or less. Echocardiographic follow-up showed no residual mitral regurgitation more than grade I in all redo mitral valve repairs and no paravalvular leak post-valve replacement. Redo-PAS-PAS is our routine approach and we apply this strategy in the majority of patients who had previous port access surgery. The predicted procedure-related mortality, morbidities, patient satisfaction and long-term outcomes are favourable.

Robotic mitral valve repairs in 300 patients: A single-center experience

Mitral valve repair is the standard therapy for patients with degenerative (myxomatous) disease and severe mitral regurgitation. Robotic mitral valve repair provides the least-invasive surgical approach. We report the largest single-center robotic mitral valve repair experience. Between May 2000 and November 2006, 300 patients underwent a robotic mitral valve repair (daVinci Surgical System; Intuitive Surgical, Inc, Sunnyvale, Calif). All operations were done with 3- to 4-cm right intercostal access, transthoracic aortic occlusion, and peripheral cardiopulmonary bypass. Repairs included 1 or a combination of trapezoidal/triangular leaflet resections, sliding plasties, chordal transfers/replacements, edge-to-edge approximations, and ring annuloplasties. Echocardiographic and survival follow-up were 93% and 100% complete, respectively. There were 2 (0.7%) 30-day mortalities and 6 (2.0%) late mortalities. No sternotomy conversions or mitral valve replacements were required. Immediate postrepair echocardiograms showed the following degrees of mitral regurgitation: none/trivial, 294 (98%); mild, 3 (1.0%); moderate, 3 (1.0%); and severe, 0 (0.0%). Complications included 2 (0.7%) strokes, 2 transient ischemic attacks, 3 (1.0%) myocardial infarctions, and 7 (2.3%) reoperations for bleeding. The mean hospital stay was 5.2 +/- 4.2 (standard deviation) days. Sixteen (5.3%) patients required a reoperation. Mean postoperative echocardiographic follow-up at 815 +/- 459 (standard deviation) days demonstrated the following degrees of mitral regurgitation: none/trivial, 192 (68.8%); mild, 66 (23.6%); moderate, 15 (5.4%); and severe, 6 (2.2%). Five-year Kaplan-Meier survival was 96.6% +/- 1.5%, with 93.8% +/- 1.6% freedom from reoperation. Robotic mitral valve repair is safe and is associated with good midterm durability. Further long-term follow-up is necessary.

Robotic Mitral Valve Repair for Anterior Leaflet and Bileaflet Prolapse

Centers have expanded indications for robotic mitral valve repairs to include complex pathologic features. We studied our results after robotic mitral valve repair for anterior leaflet or bileaflet prolapse. Data were collected contemporaneously on 289 patients operated on from May 2000 to September 2006. Every patient underwent preoperative transesophageal echocardiography. Follow-up consisted of serial echocardiograms, clinic visits, and phone conversations with patients and their physicians. A total of 66 patients (anterior leaflet, n = 14; and bileaflet, n = 52) were identified. Mean age was 52.6 +/- 7.1 years, and 57 (86%) patients had New York Heart Association functional class II or III symptoms. Cardiopulmonary bypass and cross-clamp times were 171 +/- 52 and 132 +/- 39 minutes, respectively. The 30-day and late mortality rates were 3% (n = 2) for each time point. There were no device-related or perfusion-related complications or sternotomy conversions. Complications included 2 strokes (3%), 2 bleeding reexplorations (3%), and 10 pleural effusions requiring intervention (15%). The length of hospital stay for surviving patients was 5 +/- 3 days, and time to extubation averaged 9.5 +/- 13 hours. A total of 6 (9%) patients required valve reoperation. Mean follow-up was 795 +/- 495 days, and echocardiographic mitral regurgitation (n = 60) was none or trace (n = 35, 58.3%), mild (n = 19, 31.6%), moderate (n = 2, 3.3%), and severe (n = 4, 6.7%). Robotic mitral valve repair for anterior leaflet and bileaflet prolapse is feasible and safe. Outcomes and degree of late mitral regurgitation are similar to series using conventional techniques. Long-term follow-up is required to formally address the efficacy of robotic repair techniques.