Thoracotomy Approach Research Articles

Comparison of Sternotomy Access Versus Thoracotomy Access in the Surgical Treatment of Aortic Coarctation: A Propensity Score-matched Study.

The search for the "Holy Grail" of surgical repair for aortic coarctation involves finding an access and correction method that successfully and consistently avoids aortic recoarctation and arterial hypertension. The controversy persists as there is still no consensus on the best surgical approach and technique to achieve these objectives. The objective of this study is to compare sternotomy and left thoracotomy as surgical techniques for treating patients with aortic coarctation and hypoplasia of the distal aortic arch. From January 2008 to December 2020, 103 surgical procedures were performed using an extended oblique anastomosis. The patients were divided into 2 groups: oblique, extended anastomosis from thoracotomy access (n-68; 66%) and oblique extended anastomosis from sternotomy access (n-35; 34%). After performing a propensity score analysis (1:1) for the entire sample, 25 patients from sternotomy access were matched with 25 patients from thoracotomy access. The mortality rate in the thoracotomy group was 4%, with 1 patient, while it was 8% with 2 patients in the sternotomy group, p > 0.99. There were no significant differences in early postoperative complications between the two groups. Recurrence of aortic coarctation was observed more frequently in the thoracotomy group (20.8% vs 0%). Low weight was identified as the only risk factor for aortic re-coarctation. The mortality rates and early postoperative complications associated with the surgical repair of aortic coarctation were similar between the sternotomy and thoracotomy approaches. Nevertheless, sternotomy approach may be beneficial in reducing aortic recoarctation.

Right anterior thoracotomy vs. upper hemisternotomy for aortic valve replacement with Perceval S: is there a difference?

Our study aimed to evaluate the early outcomes of aortic valve replacement with Perceval S sutureless valve through the right anterior thoracotomy and upper hemisternotomy approaches, and to determine if there are any differences between these two approaches. We carried out a study using data from 174 patients who underwent minimally invasive Perceval S valve implantation for aortic valve stenosis between January 2018 and August 2023. This was a retrospective, single-center observational study. The patients were divided into two groups: the hemisternotomy group (n = 100) and the right anterior thoracotomy group (n = 74). The overall in-hospital mortality was 1,7%. The cardiopulmonary bypass and cross-clamp times were longer in the right anterior thoracotomy group (p < .001). There were no statistically significant differences in terms of stroke, paravalvular leak, mechanical ventilation time, blood transfusion requirements, pacemaker implantation, reexploration for bleeding, conversion, wound infection, or in-hospital stay. Postoperative chest drainage was lower (p < .001) and postoperative atrial fibrillation occurred less frequently (p = .044) in the right anterior thoracotomy group. The median intensive care unit stay was shorter in the right anterior thoracotomy group (p = .018). Aortic valve replacement with the Perceval S valve through either an upper hemisternotomy or a right anterior thoracotomy is a procedure associated with low perioperative complication rates. Right anterior thoracotomy for an aortic valve replacement with the Perceval S valve was associated with lower postoperative bleeding, a lower postoperative atrial fibrillation incidence and a shorter intensive care unit stay compared to upper hemistornotomy.

Right thoracotomy with central cannulation for valve surgery: 10 years of experience.

The aim of this study is to report the early outcomes of valvular heart surgeries performed via the right thoracotomy approach. While thoracotomy with femoro-femoral bypass is an established method for minimally invasive open-heart surgeries, thoracotomy with conventional cannulation is still being explored. In our center, we conducted 958 valvular heart surgery cases using the right anterolateral thoracotomy approach with central cannulation and data were analyzed. This is a retrospective observational study based on prospectively collected data from patients who underwent valvular heart surgery at our center spanning from April 2013 to April 2023. The data encompass demographics, procedures, operative techniques, post-operative morbidity, mortality, and a 1-month follow-up. Our study revealed no procedure-related mortality. No patient required conversion to median sternotomy. Smooth cannulation and satisfactory exposure were achieved in all patients. The study encompassed a wide age range, from 14 to 68 years, with 618 female patients (64.5%) and 340 male patients (35.5%). The average cross-clamp time ranged from 38 to 90min, the duration of cardio-pulmonary bypass ranged from 45 to 105min, post-operative extubation ranged from 3 to 8h, the average drain volume ranged from 100 to 350ml, and the incision size ranged from 5 to 7cm. Our data demonstrate that conventional cannulation via the right antero-lateral thoracotomy approach for valvular heart disease is a viable alternative to reduce the side effects associated with sternotomy and femoral cannulation. This procedure is safe, reproducible, and provides the same level of treatment quality.

Pulmonary artery mass with PIK3CA mutation after orthotopic heart transplantation

BackgroundPatients can develop de novo malignancies following orthotopic heart transplantation. However, vascular tumors are not commonly described in this population.Case presentationWe present a 69-year-old female with a history of orthotopic heart transplantation for chemotherapy-induced cardiomyopathy who developed an incidental pulmonary artery mass six years after her transplantation. Given concerns for malignancy, the patient underwent an operative excisional biopsy through a left anterior mini-thoracotomy with femoral artery and vein cannulation for cardiopulmonary bypass. The mass was determined to be a non-malignant vascular overgrowth with PIK3CA mutation.ConclusionWe present the case of an unusual pulmonary artery mass with PIK3CA mutation found in a post heart transplant patient. We were able to spare her the morbidity of a redo-sternotomy by excising the mass via a minimally invasive left anterior thoracotomy approach.

PRESENTATIONS AND OUTCOMES OF AORTOFEMORAL BYPASS GRAFTING

Objectives: The aim of the study is to study presentations and clinical outcomes in patients undergoing Aortofemoral Bypass Grafting Surgery (AFB). Design: This was a Hospital based prospective study. Materials And Methods: During 18 months period , 20 patients (mean age = 56 years) underwent AFB. Indications comprised of occlusive disease with Intermittent Claudication (IC) (n=10), Critical Limb Ischaemia (CLI)(n=4), Resting Pain (RP) (n=4) and Tissue Loss (TL) (n=2). Results: From Jan 2023 to June 2024, AFB was performed more frequently for IC (50%) vs rest of other indications. 30 day observations / follow up showed infection in 5%, Graft occlusion in 5% for which patient underwent emergency graft thrombectomy, Amputation in 10% due to gangrenous changes and 15% mortality. Graft patency was found to be triphasic in 90% cases. Hypertension was leading risk factor (85%) followed by Diabetes Mellitus(70%) and smoking (65%). Predictors of morbidity included CKD (25%), CAD (25%), COPD (20%), CVA (20%).90% Patients were operated via thoracotomy approach and 10% were operated via abdominal approach depending on level of aortic thrombus. 20% of patients had previous history of endovascular interventions followed by stent occlusion. Conclusion: In era of endovascular intervention, Aortofemoral Bypass Surgery is more likely to be performed for Intermittent Claudication and graft patency has a better outcome.

Uniportal Laser-Assisted Video-Assisted Thoracoscopy (U-LA-VATS) for Lung Metastasectomy: Technical Description, Peri-Operative Results and Pertinent Literature Review.

Pulmonary metastasectomy (PM) is a well-established treatment that is able to contribute to the cure of oligometastatic cancer. Surgery should adopt the most lung-sparing approach possible to preserve pulmonary function (and, consequently, the quality of life) and to spare the lung for potential additional lung resections. In this framework, laser technology has been introduced in recent decades, but only few experiences combining laser technology with VATS approaches have been reported till now. The main focus of this manuscript is to report our institutional experience in performing lung-sparing laser-assisted PM by uniportal VATS (uniportal laser-assisted VATS: U-LA-VATS). The surgical technique and peri-operative results from our series of patients were herein presented and compared with the pertinent literature. Methods: Between March 2021 and November 2023, among 98 patients who underwent PM, a total of 24 patients (18 men (75%); 6 women (25%); mean age 61.4 years; age range 13-83 years) were treated with laser-assisted PM at our institution. Patients who underwent anatomical resection were excluded for the purpose of the analysis. The U-LA-VATS procedure adopted a modified laser-assisted lung resection technique for performing PM via VATS. Dedicated instruments are used, characterized by a long shape and a curved shape, with distal and proximal articulations. A surgical laser system (Thulium + Diodo OUTPUT 30-10 W, Quanta System S.p.a., Solbiate Olona, Italy) was used, and a 550-μm sterile optical fibre conducted through a specific thoracoscopic handpiece was introduced in the lowest part of the incision. Peri-operative results were analysed in all cohort and compared according to the surgical technique. Moreover, these results were compared with those reported in the literature. Comprehensive research of the literature was conducted on PubMed from 2000 to 2024. A review was performed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: In 12 cases (50%), thulium laser-assisted resection was performed using uniportal video-assisted thoracic surgery (VATS), and in the other cases (12, 50%), a (mini)thoracotomy access was adopted. In the thoracotomy group, the mean duration of surgery was 95 ± 57.7 min; meanwhile, it was 73.5 ± 35.5 in the uniportal VATS group. At the univariate analysis, this difference resulted to be statistically significant (p value 0.025). We did not observe intra-operative complications or remarkable malfunction of the laser system. We also did not report major complications after surgery; also the air-leak rate was 8.3% and 0% after thoracotomic and VATS procedures, respectively. Surgical margins were free from disease in all cases. Major and minor post-op complication rates were similar in both groups. The mean hospitalization after surgery was 2.9 ± 0.3 days for the uniportal VATS group and 3.7 ± 0.9 days for the thoracotomy group, this difference being statistically significant at the univariate analysis (p value = 0.015). Conclusions: U-LA-VATS is a safe and effective procedure, able to combine a parenchymal sparing exeresis with a mini-invasive approach. This procedure is associated with a shorter hospital stay compared with PM performed by a thoracotomic approach. Compared with the selected works for the review, our series is the only one describing the use of laser resection combined with a uniportal VATS approach.

Minimally Invasive Surgical Repair of Simple Congenital Heart Defects Using the Right Vertical Infra-Axillary Thoracotomy Approach.

To evaluate the safety and efficacy of surgical repair for patients diagnosed with simple congenital heart defects (CHD) using the minimally invasive right vertical infra-axillary minithoracotomy (RVIAT) approach. We retrospectively reviewed the clinical data of consecutive patients who underwent minimally invasive RVIAT for repair of CHD between August 2019 and August 2022. There were 382 patients who underwent 8 primary procedures and were included in this study. The median age of the patients was 16.2 (interquartile range [IQR], 7.2 to 41.9) months, and the median weight of the patients was 8.8 (IQR, 6.5 to 14) kg. The preoperative diagnoses were as follows: ventricular septal defect, atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, cor triatriatum, complete atrioventricular septal defect, and myxoma. The mean aortic cross-clamp time, bypass time, and operation time were 45.4 ± 19.3 min, 65.6 ± 23.1 min, and 154.5 ± 29.7 min, respectively. There was no in-hospital mortality or conversion to median sternotomy. Two patients (0.5%) required early reoperation; 1 due to postoperative bleeding and 1 for permanent pacemaker implantation. Other complications included trivial residual shunts (23 of 382, 6%), pleural effusion (3 of 382, 0.8%), pneumothorax (0.8%), and wound infection (4 of 382, 1%). There were 2 late noncardiac deaths. Late reoperation was performed on 1 patient with progressive aortic valve regurgitation who required aortic valvuloplasty. RVIAT is a minimally invasive approach that can be safely performed on patients with simple CHDs. RVIAT may be a good alternative approach for median sternotomy and cardiac intervention.

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 &lt; 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 &gt; 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.

Minimally Invasive Mitral Valve Surgery Using a Cold Fibrillatory Cardiac Arrest Technique in Patients With Prior Cardiac Surgery.

Minimally invasive mitral valve surgery (mini-MVS) is typically reserved for patients who have not undergone open cardiac surgery. In the reoperative setting, using intrapericardial dissection for crossclamping the aorta through a minimally invasive approach can be difficult and, at times, risky. Cold fibrillatory cardiac arrest (CFCA) with systemic cardiopulmonary bypass without cross-clamping is a well-described technique; however, data about its safety for patients who undergo reoperative mini-MVS are limited. Data for 34 patients who underwent reoperative mini-MVS with CFCA from March 2017 to March 2022 were reviewed retrospectively. A mini right thoracotomy (n = 30) or robotic (n = 4) approach was used. Systemic hypothermia was induced to a target temperature of 25 °C. Patient mean (SD) age was 64.5 (9.6) years, and 15 of 34 (44.1%) patients were women. Of those 34 patients, 23 (67.6%) had severe regurgitation, and 11 (32.4%) had severe stenosis. Before mini-MVS, 28 patients had undergone valve surgery, and 8 had undergone coronary artery bypass graft surgery. The mitral valve was repaired in 5 of 34 (14.7%) and replaced in 29 of 34 (85.3%) patients. No difference was observed in preoperative and postoperative left ventricular function (P = .82). In 1 patient, kidney failure developed that necessitated dialysis. No postoperative stroke or mortality at 30 days occurred. Mini-MVS with CFCA is well tolerated in patients with prior cardiac surgery. Myocardial function was not impaired, nor was the risk of stroke increased in this cohort, indicating that CFCA is a safe alternative in this high-risk population.

Features and outcomes of bilateral anatomical lung resections in patients with lung cancer

The aim of this study was to evaluate the feasibility and safety of sequential bilateral anatomical lung resections performed via video-assisted thoracic surgery (VATS) or thoracotomy approaches in lung cancer patients, as well as to identify factors affecting the postoperative period. Material and Methods. Of 534 NSCLC patients undergoing anatomical lung resection in Center for Intensive Pulmonology and Thoracic Surgery from 2014 to 2022, 14 patients with consecutive bilateral anatomical lung resections were included in the retrospective study. The patients were divided into two groups depending on a surgical approach used during the first surgery: group I – 5 patients underwent thoracotomy and group II – 9 patients underwent videoassisted thoracic surgery (VATS). The groups were matched for gender, age, smoking, Charlson Comorbidity Index, lung resection, functional status and stage of the disease. Surgical treatment included anatomical lung resection and ipsilateral systematic lymph dissection. Results. There were significant differences in intraoperative blood loss between the groups. Postoperative complications after surgery on the contralateral lung were observed more often in group 1 patients than in group II patents. The overall 5-year survival rates in patients of groups 1 and 2 were 60 % and 86 %, respectively. Respiratory function indicators three months after surgery corresponded to preoperative prognosis, and their decrease did not depend on the surgical approach used. In comparison with patients who underwent standard unilateral lung resection, bilateral anatomical lung resection was not associated with increased number of “major” complications, however, an increase in the frequency of prolonged air discharge was noted (26 % vs 6 %; p&lt;0.05). Conclusion. Sequential bilateral anatomical lung resections are feasible and safe after thorough preoperative assessment of the functional reserves of the cardio-respiratory system. Mini-invasive technologies make it possible to reduce the frequency of complications in the early postoperative period. The use of the VATS approach makes it possible to safely perform anatomical resection of the contralateral lung.

Deep Circulatory Arrest and Left Thoracotomy Approach Allow Open Repair of Chronic IIIb Dissection Associated to a Large Aortic Arch: A Case Series

Thoracic aortic aneurysms evolving within a type IIIb chronic aortic dissection are mostly treated with the deployment of an endograft. However, several cases of dissecting aneurysms are associated with a significant dilatation of the aortic arch. These cases are usually managed in two steps : arch reconstruction or supra-aortic trunk debranching at first and a secondary graft deployment for the descending thoracic aorta.We present through this case series an alternative approach for this severe condition which consists in the replacement of the thoracic aorta from its hemi-arch to the distal thoracic or visceral aorta using a left thoracotomy. We deliberately neglected the remaining dissecting aorta if its diameter was below 45 mm, hypothesizing its non evolution after repair.From 2012 to 2021, 9 patients have been treated for a thoracic aneurysm evolving after a IIIb chronic aortic dissection using a left thoracotomy and a 19°C circulatory arrest.Immediate postoperative results show no mortality nor neurological disorders and the 7 years follow up for all of these 9 cases enlightened the absence of aneurysmal evolution especially for the distal anastomosis and the remaining dissected aorta.This work suggests that this direct approach strategy can definitively treat a thoracic dissecting aneurysm unsuitable for a simple endovascular treatment.

Partial cardiopulmonary bypass through left thoracotomy for coarctation repair in children

BackgroundA left thoracotomy approach is anatomically appropriate for childhood aortic coarctation; however, the pediatric femoral arteriovenous diameters are too small for cardiopulmonary bypass cannulation. We aimed to determine the safety of a partial cardiopulmonary bypass through the main pulmonary artery and the descending aorta in pediatric aortic coarctation repair.MethodsWe retrospectively reviewed 10 patients who underwent coarctation repair under partial main pulmonary artery-to-descending aorta cardiopulmonary bypass with a left thoracotomy as the CPB group. During the same period, 16 cases of simple coarctation of the aorta repair, with end-to-end anastomosis through a left thoracotomy without partial CPB assistance, were included as the non-CPB group to evaluate the impact of partial CPB.ResultsThe median age and weight at surgery of the CPB group were 3.1 years (range, 9 days to 17.9 years) and 14.0 (range, 2.8–40.7) kg, respectively. Indications for the partial cardiopulmonary bypass with overlap were as follows: age > 1 year (n = 7), mild aortic coarctation (n = 3), and predicted ischemic time > 30 min (n = 5). Coarctation repair using autologous tissue was performed in seven cases and graft replacement in three. The mean partial cardiopulmonary bypass time, descending aortic clamp time, and cardiopulmonary bypass flow rate were 73 ± 37 min, 57 ± 27 min, and 1.6 ± 0.2 L/min/m2, respectively. Urine output during descending aortic clamping was observed in most cases in the CPB group (mean: 9.1 ± 7.9 mL/kg/h), and the total intraoperative urine output was 3.2 ± 2.7 mL/kg/h and 1.2 ± 1.5 mL/kg/h in the CPB and non-CPB group, respectively (p = 0.020). The median ventilation time was 1 day (range, 0–15), and the intensive care unit stay duration was 4 days (range, 1–16) with no surgical deaths. No major complications, including paraplegia or recurrent coarctation, occurred postoperatively during a median observation period of 8.1 (range, 3.4–17.5) years in the CPB group. In contrast, reoperation with recurrent coarctation was observed in 2 cases in the non-CPB group (p = 0.37).ConclusionsPartial cardiopulmonary bypass through the main pulmonary artery and descending aorta via a left thoracotomy is a safe and useful option for aortic coarctation repair in children.

Outcomes After Heartmate 3 Left Ventricular Assist Device Implantation Using a 10 mm Outflow Graft.

The presence of adhesions and patent bypass grafts may create challenges for standard 14 mm outflow graft placement during left ventricular assist device implantation. We retrospectively describe our experience using a 10 mm Bioline Fusion graft (Getinge, Goteborg, Sweden) as the outflow graft in patients undergoing primary Heartmate 3 (Abbott, Abbott Park, IL) implantation. One hundred one patients underwent Heartmate 3 left ventricular assist device implantation, 80% via a thoracotomy approach, with the standard 14 mm outflow graft (78) or a 10 mm Bioline Fusion outflow graft (23). Initial postoperative rotor speed-to-flow ratio (the revolutions per minutes (RPMs) required to achieve a given flow) was significantly higher in 10 mm graft patients (1,472 vs. 1,283 RPM/L/min; p = 0.03), suggesting elevated resistance in the smaller graft. Furthermore, the initial postoperative vasoactive-inotrope score was higher in the 10 mm graft patients (24.1 vs. 17.6; p = 0.022). Postoperative outcomes were similar between groups. In conclusion, the use of a 10 mm graft was associated with higher RPMs needed to generate a given flow and a higher vasoactive-inotrope score, but these differences were not associated with increased right ventricular failure or mortality.

Pathomorphological features of confirmed bronchogenic cyst with atypical localization

Among all formations of the mediastinum in the adult population, cysts make up about 20 %, of which more than 60 % are bronchogenic cysts, where up to 50% have an asymptomatic course, and therefore in most cases are detected accidentally. Regardless of the course and origin, cysts are subject to complete surgical removal. In connection with the clinical and radiological polymorphism of bronchogenic cysts, histological confirmation of the origin of the cysts does not lose its relevance. The purpose of the work is to study and highlight the pathomorphological characteristics of a cyst localized in the pericardium. Using video-assisted thoracic surgery (VATS) and thoracotomy approaches, 16 people aged 28 to 62 with cystic lesions of the mediastinum were operated on. The patients underwent radiographic examination, computed tomography with intravenous contrast injection and, in 2 cases, magnetic resonance imaging. Ultrasound examination was performed on 6 patients in whom cystic lesions were a diagnostic finding. The location of the cyst, maximum diameter, density, and calcification were evaluated. Clinically and radiologically, asymptomatic pericardial (coelomic) cysts were detected in 2 persons in the prevascular department. In the visceral part of the mediastinum, 3 patients had a pericardial cyst, 10 patients were diagnosed with 10 bronchial cysts with parenchymal and perihilar localization, among which one patient was diagnosed with an asymptomatic bronchial cyst with an atypical localization in the pericardium. In the paravertebral part of the mediastinum, 1 paraesophageal cyst was established, which was intimately connected with the lower third of the thoracic part of the esophagus. All types of cysts were histologically confirmed. Statistical processing of the obtained results was carried out using the Excel program. After a clinical examination of a patient with a pericardial cyst of the visceral mediastinum, right VATS surgery and removal of the cyst was performed. Histological examination of fragments of the cyst wall showed the presence of multi-rowed ciliated cylindrical epithelium, pronounced infiltration by lymphoid elements with hemorrhages and foci of fibrotization in separate areas. The histological structure of the removed pericardial cyst confirmed its bronchogenic origin. So, we discovered a rare form of abnormality of embryonic growth of the ventral part of the foregut with localization of a bronchogenic cyst in the anterior-inferior mediastinum on the right, which significantly expanded the understanding of the disease.

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

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

A 20–YEAR FOLLOW–UP OF SUCCESSFUL SURGICAL MANAGEMENT OF DOUBLE–OUTLET RIGHT VENTRICLE WITH PULMONARY STENOSIS: A CASE REPORT

Abstract A 25–year–old man, suffering from worsening exertional dyspnea for 4 months, was referred to our Cardiology Unit. The patient was previously diagnosed with a late diagnosis of double outlet right ventricle (DORV), as well as pulmonary stenosis, VSD, and right–sided aortic arch for which he underwent a first surgical procedure around the age of 2 involving an intersternal anastomosis through a left lateral thoracotomy approach. A second intervention took place 2 years later for a radical correction of the anomaly through a median sternotomy. The patient had sporadic follow–up since then. A baseline ECG was performed, showing evidence of sinus rhythm, normal AV with a bifid P wave in lead II, slight RAD, incomplete RBBB, and asymmetric negative T waves from V1 to V3 and in aVL, and biphasic T waves in V4–V5. We performed an echocardiogram which showed: a dilated RA, a normal–sized LA, an apparently intact interatrial septum without evident shunts; a normal sized LV; EF 60%; a moderately dilated, hypertrophic and hypertrabeculated RV; FAC 33%; normal aortic flow; a minimal MR; a massive residual pulmonary insufficiency; a moderate TR; a dilatated pulmonary trunk; a normal–sized and collapsible IVC upon inspiration; PAPs of 70 mmHg; no pericardial effusion. A maximal exercise stress test appeared to be normal throughout. However, due to the severe pulmonary hypertension he was referred to our PH centre. While these patients are commonly affected by residual early or late left ventricular outflow tract obstruction, fortunately our patient was not. DORV is a relatively common congenital heart defect characterized by an abnormal connection between the ventricles and arteries, in which both the aorta and the pulmonary trunk are connected completely or predominantly to the right ventricle. The anatomical spectrum of this anomaly is quite large, and it can be associated with the presence of a VSD that often extends towards one or both of the arterial valves, allowing the flow of blood from the left ventricle to the aorta. An accurate diagnosis through echocardiography or CMR is essential in order to guide the surgical repair and the appropriate therapeutic approach for individuals affected by this anomaly. A successful surgical correction of DORV is essential, but it is important to be aware of the potential complications of post–operative PH (especially in patients with preoperative PH), which necessitates close surveillance and appropriate therapeutic management.

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.

Successful launch of robot-assisted mitral valve repair in Japan under universal health coverage

ObjectivesWe compared the clinical outcomes of mitral valve repair for mitral regurgitation via the robot-assisted approach and small right thoracotomy approach 3 years after the reimbursement of the robot-assisted approach in Japan. MethodsPatients who underwent isolated mitral valve repair by minimally invasive approach between 2018 and 2020 from the Japan Cardiovascular Surgery Database were included. Patients in the robot-assisted approach group were matched to the small right thoracotomy approach group based on propensity scores estimated from patient and surgical characteristics. Perioperative outcomes were compared among all cases as well as in subgroups categorized on the basis of the yearly number of robot-assisted approach cases and small right thoracotomy approach cases (≥10 or <10) at the hospital. ResultsWe identified 2443 patients who had undergone isolated mitral valve repair at 250 institutions in the database, and analysis of propensity-matched 577 patient-pairs demonstrated that operation time, cardiopulmonary bypass time, and aortic crossclamp time were significantly shorter with the robot-assisted approach. Although the intensive care unit stay was longer in the robot-assisted approach, the time to discharge was significantly shorter in the robot-assisted approach. There was no meaningful difference in the in-hospital mortality. The incidences of postoperative stroke, renal failure, and prolonged ventilation, and the number of patients who converted to mitral valve replacement were similarly low. Procedural time, blood transfusions, explorative procedures for bleeding, postoperative stroke, and prolonged ventilation occurred at a lower rate in the high-volume institutions. ConclusionsThe study found that the robot-assisted approach is just as effective as the small right thoracotomy approach. The introduction of robot-assisted mitral valve repair in Japan has been successful.

Comparison of clinical effects of coronary artery bypass grafting between left anterior small thoracotomy approach and lower-end sternal splitting approach.

To compare the clinical effects of coronary artery bypass grafting (CABG) between the left anterior small thoracotomy (LAST) and lower-end sternal splitting (LESS) approaches for coronary artery disease. In total, 110 patients who underwent LAST from October 2015 to December 2020 in Tianjin Chest Hospital were selected as the observation group. Patients who underwent the LESS approach during the same period were analyzed. The propensity score was calculated by a logistic regression model, and nearest-neighbor matching was used for 1:1 matching. The length of hospital stay and ventilator support time were significantly shorter in the LAST than LESS group. The target vessels in the obtuse marginal branch and posterior left ventricular artery branch grafts were significantly more numerous in the LAST than LESS group, but those in the right coronary artery graft were significantly less numerous in the LAST group. CABG using either the LAST or LESS approach is safe and effective, especially in low-risk patients. The LAST approach can achieve complete revascularization for multivessel lesions and has the advantages of less trauma and an aesthetic outcome. However, it requires a certain learning curve to master the surgical techniques and has specific surgical indications.

A Case Report on Anesthesia Management of a Giant Thymoma Excision with a Lateral Thoracotomy Approach

A Case Report on Anesthesia Management of a Giant Thymoma Excision with a Lateral Thoracotomy Approach