Sternotomy Group Research Articles

Thoracic approaches in atrial septal defect closure a comparative study

Background: Atrial septal defects (ASD) are one of the most common cardiac malformations. Being asymptomatic, diagnosis is not always made in childhood and may be delayed to adolescence or adulthood. The incidence of ASD in female is twice that of male, so greater emphasis has been placed on the cosmetic results of the operation.Methods: In this study, we retrospectively compare results 100 patients of ASD closure through a right anterolateral thoracotomy incision and median sternotomy incision. Between August 2011 to August 2016, out of total 100 patients with ostium secundum ASD, 50 patients operated by right anterolateral thoracotomy have mean age 16.74 yrs, mean weight 28.77 kg, mean Height 122.06 cm and 50 patients with midline sternotomy have mean age 17.07 year, mean weight 29.24 kg, mean height 122.20cm.Results: There was no mortality in both groups. Per operatively mean operating time, mean CPB time, mean cross clamp time in thoracotomy was 130.08±8.16min, 48.68±5.10min, 29.70±4.21 min while in sternotomy was 121.34±8.30 min, 45.62±4.10 min, 28.28±2.82 min respectively. When compared, there is significant increased duration in operating and CPB time in thoracotomy while cross clamp time was non-significant. Mean duration of ICU and Hospital stay in thoracotomy group was 1.78±0.58days and 6.74±1.77 days when compared to sternotomy group in which it was 2.40±0.495 days and 7.66±1.40 days which is significantly less when compared. Postoperatively and in follow up thoracotomy group have better cosmesis when compared.Conclusions: Surgical treatment of osteum secondum ASD using right anterolateral thoracotomy approach has low operative risk better cosmetic results and patient satisfaction.

Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement

Propensity score-matched analysis of the anterolateral minithoracotomy and the partial upper hemisternotomy vs the median sternotomy approach has not been reported to date for isolated aortic valve replacement. From 2005 to 2013, isolated aortic valve replacement was performed through a partial upper hemisternotomy in 315 patients (38.9%), through a median sternotomy in 328 patients (40.5%), and through an anterolateral minithoracotomy in 167 patients (20.6%). After propensity score-matched analysis, both minimally invasive techniques were independently compared with median sternotomy in 118 matched pairs. In the anterolateral group, conversion to median sternotomy was significantly higher (17 [14.4%]), a second pump run (6 [5.1%]) and second cross clamp (12 [10.2%]) were significantly more often necessary, the median cross-clamp time (94 minutes; range, 43 to 231 minutes) and median perfusion time (141 minutes; range, 77 to 456 minutes) were significantly longer, and more groin complications occurred (17 [14.4%]), all compared with the median sternotomy group. No difference in perioperative results was identified between the partial upper hemisternotomy and the median sternotomy group. There was no significant difference in 1-year survival among the three groups, although a trend of better survival was observed in the partial upper hemisternotomy group. In minimally invasive isolated aortic valve replacement, the partial upper hemisternotomy shows similar perioperative outcome as the median sternotomy, whereas, the anterolateral minithoracotomy is associated with more perioperative complications. Therefore, only the partial upper hemisternotomy should be the preferred surgical technique for minimally invasive aortic valve replacement in the daily routine for a broad spectrum of surgeons.

Minimally invasive or conventional edge-to-edge repair for severe mitral regurgitation due to bileaflet prolapse in Barlow's disease: does the surgical approach have an impact on the long-term results?

To evaluate whether the adoption of a right minithoracotomy operative approach had an impact on the long-term results of edge-to-edge (EE) repair compared to conventional sternotomy in patients with Barlow's disease and bileaflet prolapse. We assessed the long-term results of 104 patients with Barlow's disease treated with a minimally invasive EE technique. An equal number of patients had a conventional median sternotomy EE repair for the same disease and were used as a control group. The inverse probability of treatment weighting was used to create comparable distributions of the covariates that were significantly different at baseline in the two groups. We performed a comparative analysis of the groups. No hospital deaths were observed. Follow-up was 99.5% complete (median 11.3 years). The cumulative incidence function (CIF) of cardiac death at 12 years, with noncardiac death as a competing risk, showed no difference between the two groups ( P = 0.87). At 12 years, the CIF of recurrent MR ≥ 3+, with death as the competing risk, was 7% in the sternotomy group and 5% in the minimally invasive group ( P = 0.30), and the CIF of recurrence of MR ≥ 2+ was 15 and 14%, respectively ( P = 0.63). The type of surgical approach was not a predictor of cardiac death, reoperation, recurrent MR ≥ 3+ or recurrent MR ≥ 2+. A minimally invasive approach does not have a negative impact on the effectiveness and long-term durability of the EE repair for bileaflet prolapse in Barlow's disease. Long-term outcomes are excellent, and valvular performance remains stable over time with no evidence of mitral stenosis.

Outcome variables of right anterolateral mini-thoracotomy versus complete sternotomy in atrial septal defect closure: A randomized controlled trial

BackgroundOver the last decades, atrial septal defect repair (ASD) as one of the most congenital anomalies has been customarily repaired via sternotomy incision. This technique is associated with very low operative risks and excellent outcomes but with poor esthetic results for the patients. Consequently, right anterolateral mini thoracotomy was invented as a substitute technique aiming for superior cosmetic results. Our study aim was to compare the perioperative outcomes for different approaches. MethodsForty patients (15 males, 25 females) with ASDs were randomly assigned to have either one of these two approaches at our institution from March 2013 until May 2016. The patients' ages ranged from 2 to 53 years old. Based on their randomization, group I (20 patients), had right anterolateral mini-thoracotomy (RALT) and group II (20 patients) who had sternotomy for surgical closure of ASD. We collected the different demographic, baseline, perioperative and postoperative characteristics. ResultsThe patients in both groups were similar in age preoperative comorbidities and ejection fraction but more females were in RALT group. There was a highly statistically significant prolonged pump-run time in the thoracotomy group than the sternotomy group with p-value = 0.004. Interestingly, in the thoracotomy group, mechanical ventilation time (hours) was shorter with p-value = 0.002. There were similar blood transfusion rate, chest tube drainage, intensive care unit stay and hospital length of stay. However, more wound infection was found in the sternotomy group which was statistically significant (p-value = 0.035). There were no patients requiring conversion to full sternotomy, no residual defect across the atrial septum and all patients were alive on a month follow-up of the hospital discharge. ConclusionsRight anterolateral mini-thoracotomy is safe, cosmetic, effective and technically feasible and not inferior to the formal median sternotomy to repair ASDs surgically.

Two-Incision Totally Thoracoscopic Approach for Mitral Valve Replacement.

Totally thoracosopic mitral valve replacement (MVR) has been applied to mitral stenosis for many years. Three working ports are usually necessary, among which the longest port ranges from 6 to 8 cm. This study aimed to determine the safety and feasibility of the two-incision totally thoracoscopic approach for MVR, with the longest incision of 3 cm.From January 2014 to February 2016, 90 patients with mitral valve stenosis were retrospectively analyzed. Thirty-six (40%) patients were included in the two-incision group and 54 patients were operated on using the sternotomy approach. Perioperative variables and postoperative 3-month follow-up data were analyzed.All patients underwent MVR. Tricuspid valvuloplasty was performed in 23 (25.5%) patients with the Kay technique. The mean total surgery time, cardiopulmonary bypass, and cross-clamp times were longer in the two-incision group (266 ± 42 versus 200 ± 38 minutes; 156 ± 23 versus 121 ± 21 minutes; 100 ± 17 versus 80 ± 17 minutes, respectively) (P < 0.05). The mean postoperative mechanical ventilation time was shorter in the two-incision group (8.6 ± 2.5 versus 11.2 ± 2.6 hours, respectively) (P < 0.05). The mean volume of blood drainage was less in the two-incision group (497 ± 120 versus 730 ± 198 mL, respectively) (P < 0.05). Reopening occurred in one (sternotomy group, 1.8%) patient. No deaths, perivalvular leakage, infectious endocarditis, atelectasis of the lungs, or moderate tricuspid regurgitation were found at the 3-month follow-up.The two-incision totally thoracoscopic approach for MVR is safe and feasible. Concomitant tricuspid valvuloplasty can be conveniently performed. However, further clinical data are needed in future studies.

EARLY OUTCOME OF THORACOSCOPIC MINIMALLY INVASIVE VERSUS CONVENTIONAL MITRAL VALVE SURGERY IN MITRAL VALVE DISEASES

Background: Minimally Invasive Mitral Valve Surgery (MIMVS) is fast becoming an established treatment option for the treatment of mitral valve disease internationally. Increased recognition of advantages, of minimizing surgical trauma and its direct impact on reduced postoperative pain, quicker recovery, improved cosmosis and earlier return to work has spurred the minimally invasive cardiac surgical revolution. Objectives: Comparing the postoperative pain, cost, hospital stay, recovery speed and pulmonary function between minimally invasive and conventional mitral surgery. Moreover, assessment of thirty day mortality and early post-operative morbidity in both techniques. Patients and methods: This study was conducted on 50 patients requiring mitral valve surgery classified into 2 equal groups: Group A (Minimally invasive group), who were approached through a right Anterolateral video-assisted minithoracotomy. Group B (Sternotomy group), who were approached through a conventional median sternotomy. Results: There was no statistical difference between the two groups in baseline pre-operative characteristics regarding their age, sex, NYHA class, EF%, LA dimension and spirometric study. There was no operative mortality in both groups. Incision length, ventilation time, blood drainage, blood transfusion, ICU stay, total hospital stay were less in group A. Conclusion: In patients with mitral valve disease, MIMVS can be an alternative to conventional mitral valve surgery with comparable short-term mortality and in-hospital morbidity.

Changes in the amount of physical activity in minimally invasive cardiac surgery.

[Purpose] This study aimed to compare the amount of physical activity in a minimally invasive cardiac surgery (MICS) group with that in a conventional surgery (median sternotomy) group. [Subjects and Methods] Between November 2010 and December 2011, 39 consecutive patients who underwent elective surgery for valvular disease were prospectively enrolled. The amount of physical activity before and after surgery was measured in 22 cases. The daily in-hospital physical activity level was measured continuously using a triaxial accelerometer. The results were compared in terms of change in the amount of physical activity pre- and postoperatively. [Results] There was no significant difference between the two groups in the amount of physical activity before surgery. However, the amount of physical activity after surgery was significantly higher in the MICS group compared with the conventional surgery group. The number of steps after surgery was significantly increased in the MICS group, and the rate of change in the amount of physical activity was significantly higher in the MICS group than that in the conventional surgery group. [Conclusion] The MICS approach is associated with improvement in postoperative physical activity over median sternotomy.

Less invasive video assisted cardiac surgery a comparative study with the conventional approach

Background-Vertical median sternotomy has been the best approach to cardiac surgery. While the conventional approach is traumatic, with many complications, using a video camera in surgery offers smaller incisions. Methods - Our study was a prospective and comparative one. Our sample consisted of 57 patients, divided into 2 groups, including 30 patients operated by vertical median sternomtomy and 27 patients operated by minimally invasive video-assisted surgery. Preoperative, operative and postoperative data were collected and analyzed. Results -The patients’mean age was 49.5+16.3 years in the minimally invasive video-assisted group and 43.4+16.7 in the vertical median sternotomy group. The most common sign among these patients was dyspnea. Asymptomatic patients represented 11% in the vertical median sternotomy group and 43% in the minimally invasive video-assisted group. Mitral valve surgery was in 63% patients of minimally invasive video-assisted and 66.6% of vertical median sternotomy group. The mean time of cardiopulmonary bypass was 119.52+44.5 min in the minimally invasive video-assisted group and 84.53+34.2 min in the vertical median sternotomy group. The mean time of aortic clamping in the minimally invasive video-assisted group was 94.56+40.8 min while it was 59.53+25.5 min in the vertical median sternotomy group. The mean time of mechanical ventilation was 4.7+1.8 hours in the minimally invasive video-assisted group and 7.9±2.4 hours in the vertical median sternotomy group. Postoperative pain disappeared on the 2nd postoperative day in (73%) of the minimally invasive video-assisted group cases and on the 5th day in (70%) of vertical median sternotomy group cases. The average hospital stay was 8.67+3.8 days in minimally invasive video-assisted and 13.8+5.0 days in vertical median sternotomy group. Faster recovery of physical activities after minimally invasive surgery was reported. Conclusion - The minimally invasive video-assisted is a simpler, safer and more effective procedure with excellent results and low morbidity. This procedure results in a short -er recovery time.

Early post-operative pulmonary function tests after mitral valve replacement: Minimally invasive versus conventional approach. Which is better?

BackgroundMinimally invasive mitral valve surgery (MIMVS) is safe, with low perioperative morbidity, and low rates of reoperation. Minimally invasive mitral valve surgery has been proven a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Efforts to minimize surgical trauma, fasten patient recovery, increase patient satisfaction, and reduce cost without compromise to surgical repair or replacement techniques, continue to be the rationale for minimally invasive procedures. In this work, the difference in pulmonary function tests between both approaches was studied among other variables. MethodsIn this study 50 patients with mitral valve disease (MVD) requiring mitral valve surgery were selected by purposive nonprobability sample. The study was done at the Armed Forces Hospitals (mainly Maadi & Galaa Armed Forces Hospitals). 25 patients attended to have mitral valve surgery by right anterolateral mini-thoracotomy (group A) with femoral artery and vein cannulation and other 25 patients by traditional sternotomy (group B). Pulmonary function tests were studied within one week preoperatively and 10 days postoperatively in both groups. ResultsThere was no statistical difference between the two groups preoperatively regarding their age, sex, NYHA class, EF%, LA dimension, and preoperative spirometric study. There was no operative mortality in both groups but fewer postoperative complications occurred in both groups with highly significant differences in favor of minimal invasive group. These included better postoperative pulmonary function tests. There was a highly significant difference in the FVC, FEV1, FVC %, FEV1 % and no significant change in FEV1/FVC between both group denoting better post operative pulmonary function of minimally invasive (group A) patients. There was also less blood loss, less postoperative blood transfusion, less total hospital stay, ICU stay, faster recovery with better cosmetic appearance, and more cost effective. ConclusionMinimally invasive right anterolateral mini-thoracotomy is as safe as median sternotomy for mitral valve surgery, with fewer complications and postoperative pain, less ICU and hospital stay, fast recovery to work with no movement restriction after surgery. There was a highly significant difference denoting better post operative pulmonary function of the minimally invasive approach.

Surgical Outcomes of Cardiac Myxoma: Right Minithoracotomy Approach versus Median Sternotomy Approach

BackgroundThe standard approach in treating cardiac myxoma is the median full sternotomy. With the evolution of surgical techniques, the right minithoracotomy approach has emerged as an alternative method. Since few studies have been published assessing the right minithoracotomy approach, we performed a retrospective study to compare the clinical outcomes of the right minithoracotomy approach with those of the sternotomy approach.MethodsFrom January 2005 to December 2014, 203 patients underwent resection of a cardiac myxoma. Patients with preexisting cardiac problems were excluded from this study. 146 patients were enrolled in this study; 83 patients were treated using a median sternotomy and 63 patients were treated using a right minithoracotomy.ResultsNo early mortalities were recorded in either group. Although the cardiopulmonary bypass time and aorta cross-clamp time were significantly shorter in the sternotomy group (p<0.001 and p=0.005), postoperative blood transfusions and arrhythmia events were significantly less common in the thoracotomy group (p=0.004 and p=0.025, respectively). No significant differences were found in the duration of the hospital stay, postoperative intubation time, the duration of the intensive care unit stay, and recurrence.ConclusionThe minimally invasive right minithoracotomy approach is a good alternative method for treating cardiac myxoma because it was found to be associated with a lower incidence of postoperative complications and a shorter postoperative recovery period.

Early outcome of minimally invasive mitral valve surgery

BackgroundMinimally invasive mitral valve surgery (MIMVS) is safe, with low perioperative morbidity, and low rates of reoperation. Minimally invasive mitral valve surgery has been proven a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Efforts to minimize surgical trauma, hasten patient recovery, increase patient satisfaction, and reduce cost without compromise to surgical repair or replacement techniques, continue to be the rationale for minimally invasive procedures. MethodsIn this study 30 patients with mitral valve disease (MVD) requiring mitral valve surgery selected by purposive non probability sample. The study was done at the Armed Forces Hospitals (mainly Maadi & Galaa Armed Forces Hospitals). 15 patients attended to do mitral valve surgery by traditional sternotomy (group B), other 15 patients by less invasive surgery (Rt. anterolateral mini-thoracotomy) (group A) with femoral artery and vein cannulation. ResultsThere was no statistical difference between the two groups preoperatively regarding their age, sex, NYHA class, EF%, LA dimension, spirometric study. There was no operative mortality in both groups but fewer postoperative complications occurred in both groups. Total hospital stay, ICU stay, postoperative bleeding, inotropic requirement, ventilatory support, blood transfusion was less in group “A”, with better cosmetic appearance, and more cost effective. ConclusionRight anterolateral mini-thoracotomy minimally invasive technique provides excellent exposure of the mitral valve, even with a small atrium and offers a better cosmetic lateral scar which is less prone to keloid formation. In addition, minimally invasive right anterolateral mini-thoracotomy is as safe as median sternotomy for mitral valve surgery, with fewer complications and postoperative pain, less ICU and hospital stay, fast recovery to work with no movement restriction after surgery. It should be used as an initial approach for mitral valve surgery. Furthermore, it was believed that less spreading of the incision, no interference with the diaphragm and less tissue dissection might improve outcomes, particularly respiratory function.

The Feasibility of Median Sternotomy With or Without Thoracotomy for Locally Advanced Non-Small Cell Lung Cancer Treated With Induction Chemoradiotherapy

This study aimed to compare the morbidity and mortality of a median sternotomy approach and a lateral thoracotomy and to investigate the feasibility of a median sternotomy for locally advanced non-small cell lung cancer (NSCLC) after induction chemoradiotherapy. The medical records of patients with locally advanced NSCLC who underwent induction chemoradiotherapy followed by surgery at our institution between January 1999 and September 2014 were reviewed. We compared the morbidity and mortality of a median sternotomy approach and a lateral thoracotomy. A total of 102 NSCLC patients were the subjects of this study. Among them, 31 patients underwent surgery with a median sternotomy approach and 71 patients underwent surgery with a lateral thoracotomy. Patients in the median sternotomy group had a significantly higher rate of postoperative arrhythmia than those in the lateral thoracotomy group (p= 0.0028). However, all the complications were manageable, and no treatment-related deaths occurred in the median sternotomy group. Regarding the prognosis, the 5-year overall survival rate was 72.7%, and the 2-year recurrence-free survival rate was 66.5% in the entire population. No significant differences in overall survival or recurrence-free survival were observed between the 2 approaches. Whereas the lateral thoracotomy approach is a standard procedure, our experience suggests that a median sternotomy approach for locally advanced NSCLC after induction chemoradiotherapy is a feasible procedure and can be a surgical option.

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

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

A Novel Minimally Invasive Approach for Surgical Septal Myectomy

BackgroundTransaortic septal myectomy is the gold standard for the treatment of symptomatic hypertrophic obstructive cardiomyopathy that is refractory to medical therapy. The aim of this study was to assess early outcomes of minimally invasive septal myectomy performed through a right anterior minithoracotomy. MethodsBetween 2011 and 2014, 24 consecutive patients underwent isolated septal myectomy through a 4-5–cm right parasternal minithoracotomy. Perioperative clinical and echocardiographic outcomes in these patients were compared with those of a historical cohort of 26 consecutive patients who underwent isolated septal myectomy performed through a median sternotomy between 2002 and 2010. ResultsAge and sex distribution were similar between the groups. Median aortic cross-clamp time was 57 minutes in the minithoracotomy group vs 43 minutes in the sternotomy group (P = 0.149). There was no in-hospital mortality in either group. Intraoperative conversion to sternotomy was required in 1 patient. Postoperative permanent pacemaker implantation was required in 5 patients from each group (P = 0.999). Both groups demonstrated similar reductions in left ventricular outflow tract gradient and septal thickness. Residual obstructive systolic anterior motion of the mitral valve was observed in 2 patients (8%) in the minithoracotomy group and 1 patient (4%) in the sternotomy group (P = 0.602). ConclusionsThis study demonstrates the feasibility of transaortic septal myectomy through a right minithoracotomy. Our early results suggest that this technique yields clinical and echocardiographic outcomes similar to those obtained with standard sternotomy.

Extended total arch replacement via the L-incision approach: single-stage repair for extensive aneurysms of the aortic arch.

Total arch replacement via the L-incision approach (a combination of left anterior thoracotomy and upper median sternotomy) can be used to achieve more extensive replacement. In the period between 2002 and 2014, 279 total arch replacement procedures were performed. After excluding cases of acute aortic dissection and cases involving concomitant, hybrid or frozen elephant trunk procedures, patients who underwent isolated total arch replacement via an L-incision (n = 29) and via median sternotomy (n = 143) were identified and the data pertaining to their cases were analysed. Operative mortality was higher in the L-incision group than in the median sternotomy group (6.9 vs 2.1%); however, the difference was not statistically significant. The L-incision group displayed a higher rate of respiratory complications, including pneumonia (28 vs 7.0%, P = 0.0034), the need for tracheostomy (17 vs 2.1%, P = 0.0038) and pulmonary haemorrhage (6.9 vs 0%, P = 0.028). The rate of paraplegia was similar between the groups (0 vs 1.4%, P = 1.00), despite the wider range replaced via the L-incision approach (7.3 ± 1.5 vs 4.7 ± 0.8 anatomical zones, P < 0.001). The rates of other complications and functional recovery were similar. The long-term survival (73 vs 84% at 5 years) and aortic event-free rates (94 vs 96% at 5 years) were similar in both groups. A combination of left anterior thoracotomy and upper median sternotomy can be applied to the single-stage repair of extended aneurysms with acceptable results in appropriately selected patients.

Submammary incision as right minithoracotomy approach with intercostal nerve exclusion and blockage technique: A comparative study in the young Indian female population undergoing mitral valve replacement

Objective: This study compares the quality of mitral valve (MV) replacement performed through a submammary right thoracotomy incision with nerve sparing opening and closure to the standard midline sternotomy procedure. Materials and Methods: Hundred young female patients underwent MV replacement with 50 patients in the thoracotomy group and the remaining 50 patients in the median sternotomy group between August 2013 and April 2014 with follow-up till August 2015. Demographics, procedures, operative techniques, and postoperative morbidity and mortality, along with follow-up, were recorded in both the patients and compared. Results: In our study, postoperative pain and postoperative drainage were significantly lower in the thoracotomy variant with 60% of the cases draining only 100-200 mL. Morbidity is quite less in the thoracotomy variant with 60% of the cases able to stand up without support postoperatively 12 h after extubation while the number is only 20% in the sternotomy variant and that too with sternal support. Most of the thoracotomy cases were discharged from the hospital within 1 week. On follow-up, there were only two cases, i.e., 4% of the total cases presenting with hypertrophied scar, which is significantly lower than 20% of the sternotomy cases where three cases developed into keloid while in the sternotomy cases, 10 (20%) cases reported with wound discharge and infection. Conclusions: This procedure provides the same quality of treatment through a less traumatic and better cosmetic incision, resulting in less hospital stay and a lower overall cost.

Clinical Experience With Sternotomy Versus Subcostal Approach for Exchange of HeartMate II Left Ventricular Assist Device

The safety and efficacy of exchanging the HeartMate II (Thoratec Corp, Pleasanton, CA) left ventricular assist device (LVAD) through a less invasive subcostal approach remains unclear. We reviewed the records of 17 patients who underwent exchange of their HeartMate II device at our institution since 2007. We divided the cohort into devices exchanged through a subcostal (SC) approach versus a median sternotomy (MS) approach and obtained data pertaining to the short- and long-term outcomes. Nine patients had pump exchange through an MS approach versus 8 patients who underwent an SC approach. The mean duration of support with the first pump was 540 ± 450 days. The reason for exchange was electromechanical failure (7 patients), thrombosis (8 patients), and infection (2 patients). There were no 30-day perioperative deaths with either approach. Compared with sternotomy, patients who underwent an SC approach had significantly shorter operative times (131 vs 222 minutes; p = 0.001) and lower reoperation rates for bleeding (0 vs 44.4%; P = 0.05) and required fewer transfused blood products (packed red cells, 3.5 units vs 7.1 units; p < 0.05; cryoprecipitate, 50.7 mL vs 209.3 mL; p = 0.01; and platelets, 292 mL versus 762 mL; p < 0.05). Additionally, patients who underwent an SC approach had shorter postoperative stays in the intensive care unit (ICU) (5 days vs 13.8 days; p < 0.05) and shorter total hospital stays (16.4 days vs 27.2 days; p < 0.05). Long-term survival after mean follow-up of 260 days for the SC group and 232 days for the sternotomy group was 75% and 33%, respectively. Exchange of the HeartMate II pump can be accomplished with low morbidity and mortality and good long-term outcomes through a less invasive SC approach.

Quality of life after robotically assisted atrial myxoma excision.

The aim of this study was to evaluate the clinical outcome after robotically assisted myxoma surgery performed at our institution. Altogether nine patients underwent robotically assisted atrial myxoma excision. A control group was selected from 18 consecutive patients who underwent an isolated atrial myxoma excision via conventional sternotomy. Preoperative patient characteristics were similar between the two study groups. Postoperative health-related quality of life (HRQoL) was also evaluated. All robotic operations were completed successfully using the da Vinci™ telesurgical system. There was no mortality in either of the two study groups. Procedure, cardiopulmonary bypass, aortic occlusion, and ventilation times were shorter in the sternotomy group when compared to the robotic group. Length of stay was statistically significantly shorter in the robotically assisted group. Postoperative quality of life did not differ between the two study groups. We conclude that robotically assisted surgery is a feasible method for treating atrial myxomas.

Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation

Orthotopic heart transplantation (OHT) remains the gold standard for end-stage heart failure. However, donor availability is severely limited. With a median wait time of 6.6 months and more than 12% of patients waiting 5 or more years, the decision is often made to implant a left ventricular assist device (LVAD) asa bridge to transplantation for medical stabilization. Furthermore, the number of patients who have had at least one prior sternotomy while awaiting transplantation is increasing. Previous studies have indicated reoperative sternotomy as a risk factor for compromised survival. Concerns are specifically focused on perioperative, short-term, and long-term outcomes after LVAD explantation or redo sternotomy before OHT because of increasing operative complexity. We hypothesize that despite the greater technical difficulty caused by LVAD explantation or redo sternotomy, outcomes would not be compromised. We retrospectively analyzed patients who underwent OHT at the University of Pennsylvania during a 5-year period (2008-2013; n= 253). All patients who underwent a bridge to transplantation LVAD (n= 72) or prior sternotomy (n= 65) were compared with those undergoing OHT with a virgin chest (n= 116). Preoperative, intraoperative, and postoperative variables were analyzed. Short- and long-term survival were studied (minimum follow-up, 6 months). Comorbidities were similar among the groups. There was no difference in donor allograft ischemic time (p= 0.6). However, cardiopulmonary bypass time was longer in both bridge to transplantation and prior sternotomy cohorts (p < 0.00001). The blood transfusion requirement was higher in bridge to transplantation (12.5 ± 13.7 units; p= 0.0007) and prior sternotomy groups (11.7 ± 12.9 units; p= 0.02) as compared with the virgin chest cohort (7.1 ± 10.7 units). For bridge to transplantation, both time to extubation (1.0 ± 1.6 versus 0.9 ± 1.0 days; p= 0.03) and intensive care unit length of stay (7.0 ± 7.0 versus 6.0 ± 7.0 days; p= 0.06) were longer compared with the virgin chest cohort. The same was true for prior sternotomy (extubation time, 1.9 ± 4.4 days; p= 0.005; intensive care unit length of stay, 8.0 ± 12.0 days; p= 0.06). There was no difference in hospital length of stay (p= 0.2). Overall, there was no difference in short- or long-term survival. Implantation of an LVAD as a bridge to transplantation or prior sternotomy does not adversely impact allograft function, hospital length of stay, or long-term outcomes after OHT. The decision to manage a patient medically while awaiting transplantation versus an LVAD bridge strategy should not be limited by concerns of subsequent poor outcomes after transplantation.

Minimally Invasive Port Access Approach for Reoperations on the Mitral Valve

In patients requiring a second-time or more operation on the mitral valve (MV), we assessed whether the outcomes of the minimally invasive port access approach (port access group) were equivalent to those of the traditional redo sternotomy approach (redo sternotomy group). In a retrospective review (1998-2011), 409 patients had previous MV operations requiring a second-time or more MV reintervention. Of those, 67 patients had the port access approach, and 342 had the redo sternotomy approach. Of the latter, 220 met the inclusion criteria because emergencies, patients with endocarditis, and those requiring concomitant procedures involving aortic valve and aorta were excluded. New York Heart Association class 2 or above, age, atrial fibrillation, and surgical indications were similar in both groups. The port access group had more patients with previous MV repair (78% [n = 52] vs 41% [n = 90], p < 0.01) than with MV replacement (19% [n = 13) vs 53% [n = 116], p < 0.01). Concomitant procedures were similar (20% [n = 14] vs 27% [n = 59], p = 0.4). The MV re-repair rates were similar (19% [n = 10] vs 22% [n = 20], p = 1). The cardiopulmonary bypass times (153 ± 42 minutes vs 172 ± 83 minutes, p = 0.07) and aortic cross-clamping times (104 ± 38 minutes versus 130 ± 71 minutes, p < 0.01) were lower in the port access group. Mortality was lower in the port access group, although not significantly (3.0% [n = 2] vs 6.0% [n = 13], p = 0.5). The rates of postoperative stroke were similar (3.0% [n = 2] vs 3.2% [n = 7], p = 1). On postoperative echocardiography, freedom from mitral regurgitation >2+ was 100% in the port access group and 99% in the redo sternotomy group. The mean hospital length of stay was 11 ± 15 days versus 14 ± 12 days (p = 0.07). The port access approach can be safely adopted for reoperations on the MV without compromising postoperative mortality or MV function.