Thoracotomy Approach Research Articles

The ever-changing field of mechanical circulatory support: new challenges at the advent of the 'single device era'.

The ever-changing field of mechanical circulatory support: new challenges at the advent of the 'single device era'.

Neonatal right mini thoracotomy for repair of critical pulmonary stenosis.

Over the last few decades, due to evolving surgical techniques and medical management, there has been a significant decrease in the rate of mortality and complications for neonates born with critical pulmonary valve stenosis. Median sternotomy is the standard approach; however, this longitudinal midline incision is invasive and leaves a significant scar. A right mini thoracotomy approach to this surgical repair decreases recovery time and the chance of possible future psychological distress from a visible median sternotomy scar. This is the first article to describe a right mini thoracotomy approach for critical pulmonary stenosis during the neonatal period.

Nodal Upstaging Evaluation After Robotic-Assisted Lobectomy for Early-Stage Non-small Cell Lung Cancer Compared to Video-Assisted Thoracic Surgery and Thoracotomy: A Retrospective Single Center Analysis.

Introduction: The standard surgical procedures for patients with early-stage NSCLC is lobectomy-associated radical lymphadenectomy performed by using the thoracotomy approach. In the last few years, minimally invasive techniques have increasingly strengthened their role in lung cancer treatment, especially in the early stage of the disease. Although the lobectomy technique has been accepted, controversy still surrounds lymph node dissection. In our study, we analyze the rate of upstaging early non-small cell lung cancer patients who underwent radical surgical treatment using the robotic and the VATS techniques compared to the standard thoracotomy approach.Methods and Materials: We retrospectively reviewed patients who underwent a lobectomy and radical lymphadenectomy at our Institute between 2010 and 2019. We selected 505 patients who met the inclusion criteria of the study: 237 patients underwent robotic surgery, 158 patients had thoracotomy, and 110 patients were treated with VATS. We analyzed the demographic features between the groups as well as the nodal upstaging rate after pathological examination, the number of dissected lymph nodes and the ratio of dissected lymph nodes to metastatic lymph nodes of the three groups.Results: The patients of the three groups were homogenous with respect to age, sex, and histology. The postoperative major morbidity rate was significantly higher in the thoracotomy group, and hospital stay was significantly longer. The percentage of the mediastinal nodal upstaging rate and the number of dissected lymph nodes was significantly higher in the robotic group compared with the VATS group. The ratio of dissected lymph nodes to metastatic lymph nodes was significantly lower compared with the VATS group and the thoracotomy group.Discussion: The prognostic impact of the R(un) status is still highly debated. A surgical approach that allows better results in terms of resection has still not been defined. Our results show that robotic surgery is a safe and feasible approach especially regarding the accuracy of mediastinal lymphadenectomy. These findings can lead to defining a more precise pathological stage of the disease and, if necessary, to more accurate postoperative treatment.

Impact of thoracotomy approach on right ventricular failure and length of stay in left ventricular assist device implants: an intermacs registry analysis

Traditionally, implantation of Left Ventricular Assist Devices (LVADs) is performed via median sternotomy. Recently, less invasive thoracotomy approaches are growing in popularity as they involve less surgical trauma, potentially less bleeding, and may preserve right ventricular function. We hypothesized implantation of LVADs via thoracotomy has less perioperative right ventricular failure (RVF) and shorter postoperative length of stay (LOS). Continuous flow LVAD implants from Intermacs between February 6, 2014 - December 31, 2018 were identified. Patients implanted via thoracotomy were propensity matched in a 1:1 ratio with patients implanted via sternotomy. Outcomes were compared between sternotomy and thoracotomy approach and by device type (axial, centrifugal-flow with hybrid levitation (CF-HL), centrifugal-flow with full magnetic levitation devices (CF-FML)). The primary outcome was time to first moderate or severe RVF. Secondary outcomes included survival and LOS. Overall 978 thoracotomy patients were matched with 978 sternotomy patients. Over the study period, 242 thoracotomy patients and 219 sternotomy patients developed RVF with no significant difference in time to first moderate to severe RVF by surgical approach overall (p=0.27) or within CF-HL (p=0.36) or CF-FML devices (p=0.25). Survival did not differ by implant technique (150 deaths in thoracotomy group, 154 deaths in sternotomy group; p=0.58). However, sternotomy approach was associated with a significantly shorter LOS (17 Vs 18 days, p=0.009). As compared to sternotomy, implantation of continuous flow LVADs via thoracotomy approach does not reduce moderate to severe RVF or improve survival but does reduce post-operative LOS. Device type did not influence outcomes and most centers did a small volume of thoracotomy implants.

Limited upper mini-sternotomy approach for closed heart surgery in the newborns and infants.

The mini-sternotomy has become a common approach of choice for a wide range of congenital defects requiring minimally invasive surgery. Here, we aimed to present closed heart surgery results via limited upper mini-sternotomy in the newborn and infants. A total of 46 infants who underwent pulmonary artery banding, patent ductus arteriosus ligation, and aortopexy via limited upper mini-sternotomy between December 2017 and October 2020 were enrolled. Patients included 26 males and 20 females with ages ranging from 2days to 12months (median age 3.25 ± 0.9months). The weight ranged from 0.7kg to 8kg (median weight 3.6 ± 1.8kg). These patients were evaluated retrospectively in terms of clinical, preoperative, intraoperative, and postoperative parameters. Closed heart surgery procedures were corrected successfully without adverse events intraoperatively. The median operation time was 32min (32 ± 7min). The limited upper mini-sternotomy was performed on 46 patients, including the pulmonary banding (18 patients), PDA ligation (16 patients), and aortopexy (12 patients). No patients required conversion to full sternotomy or to extend the incision. Re-intervention to adjust the tightness of the band was required in 1 patient. There were 4 cases of mortality (8.6%). All four death cases had comorbidity and low birth weight (2500g or less). Limited upper mini-sternotomy is a technically feasible, safe, and effective approach that providing an adequately surgical view in closed heart surgery to reduce the invasiveness of the closed heart surgical repair via median sternotomy or thoracotomy approach.

Safety and efficacy of transcatheter tricuspid valve replacement with LuX-Valve in patients with severe tricuspid regurgitation

Objectives: To evaluate the safety and efficacy of LuX-Valve on the treatment of severe tricuspid regurgitation (TR). Methods: This is a prospective observational study. From September 2018 to March 2019, 12 patients with severe TR, who were not suitable for surgery, received LuX-Valve implantation in Changhai Hospital. LuX-Valve was implanted under general anesthesia and the guidance of transesophageal echocardiography and X-ray fluoroscopy. Access to the tricuspid valve was achieved via a minimally invasive thoracotomy and transatrial approach. Main endpoints were surgery success and device success. Surgery success was defined as successful implanting the device and withdrawing the delivery system, positioning the valve correctly and stably without severe or life-threatening adverse events. Device success was defined as satisfied valve function (TR severity reduction ≥ 2 grades, tricuspid gradient ≤ 6 mmHg (1 mmHg=0.133 kPa)), absence of malposition, valve failure and reintervention, major adverse events including device related mortality, embolization, conduction system disturbances and new onset shunt across ventricular septum at day 30 post implantation. Results: A total of 12 patients with severe to torrential TR were included in this study. The age was (68.5±6.9) years and 7 were female. All patients had typical right heart failure symptoms. Procedural success was achieved in all cases, there was no intraprocedural mortality or transfer to open surgery. TR significantly improved after LuX-Valve implantation (none/trivial in 8 patients, mild in 3 patients and moderate in 1 patient). The average device time was (9.2±4.2) minutes. Intensive care unit duration was 3.0 (2.0, 4.8) days. One patient died at postoperative day 18 due to non-surgery and device reasons. Transthoracic echocardiography at 30 days after operation showed that TR was significantly reduced (none/trivial in 8 patients, mild in 2 patients and moderate in 1 patient) and device success was achieved in 11 cases. All survived patients experienced a significant improvement in life quality with significantly improvement in New York Heart Association (NYHA) classification (Ⅰ and Ⅱ: 6/11 post operation vs. 0/11 before operation, P=0.012) and there were no device related complications in this patient cohort. Conclusions: LuX-Valve implantation is feasible, safe and effective for the treatment of patients with severe TR.

Advantages of a mini right axillary thoracotomy for congenital heart defect repair in children.

The mini right axillary thoracotomy is an alternative surgical approach to repair certain congenital heart defects. Quality-of-life metrics and clinical outcomes in children undergoing either the right axillary approach or median sternotomy were compared. Patients undergoing either approach for the same defects between 2018 and 2020 were included. Demographic details, operative data, and outcomes were compared between both groups. An abbreviated quality of life questionnaire based on the Infant/Toddler/Child Health Questionnaires focused on the patient's global health, physical activity, and pain/discomfort was administered to all parents/guardians within two post-operative years. Eighty-seven infants and children underwent surgical repair (right axillary thoracotomy, n = 54; sternotomy, n = 33) during the study period. There were no mortalities in either group. The right axillary thoracotomy group experienced significantly decreased red blood cell transfusion, intubation, intensive care, and hospital durations, and earlier chest tube removal. Up to 1 month, parents' perception of their child's degree and frequency of post-operative pain was significantly less after the right axillary thoracotomy approach. No difference was found in the patient's global health or physical activity limitations beyond a month between the two groups. With the mini right axillary approach, surrogates of faster clinical recovery and hospital discharge were noted, with a significantly less perceived degree and frequency of post-operative pain initially, but without the quality of life differences at last follow-up. While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of certain congenital heart lesions is a safe alternative to median sternotomy.

Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center.

The goal of this manuscript was to report the clinical outcomes of the initial series of 100 consecutive Right Anterior Mini Thoracotomy (RAMT) aortic valve replacement (AVR) implantations at a Canadian Center. This retrospective study reported the clinical outcomes of the first 100 patients who underwent the RAMT approach for isolated surgical AVR in Calgary, Canada, between 2016 and 2020. Primary outcomes were death within 30 days of surgery and disabling stroke. Secondary outcomes included surgical times, the need for permanent pacemaker (PPM), incidence of postoperative blood transfusion in the intensive care unit (ICU), postsurgical atrial fibrillation (AF), length of ICU/hospital stay, postsurgical AF, residual paravalvular leak (PVL), postoperative transvalvular gradient, need for postsurgical intravenous opioids, duration of invasive ventilation in the ICU, and chest tube output in the first 12 h postsurgery. In this study, 54 patients were male, and the average age of the cohort was 72 years. Mortality within 30 days of surgery was 1% with no disabling postoperative strokes. Mean cardiopulmonary bypass and cross clamp was 84 and 55 min, respectively. PPM rate was 3%, incidence of blood transfusion in the ICU was 4%, and the rate of postoperative AF was 23%. Median length of ICU and hospital stay was 1 and 5 days, respectively. Rate of mild or greater residual PVL was 3%, while the average residual transvalvular mean gradient was 8.5 mmHg. The sternum-sparing RAMT approach can be safely integrated into surgical practice as a minimally invasive alternative for isolated AVR, and can reduce postoperative bleeding and narcotic requirements.

Transaxillary Approach for Surgical Repair of Simple Congenital Cardiac Lesions: Pitfalls, and Complications.

In the treatment of simple congenital cardiac lesions, percutaneous and cosmetic surgical approaches have steadily gained prominence. Surgically, right vertical axillary approach is sparsely used despite superior cosmesis and less pain and blood product usage. Knowledge of potential pitfalls could lead to its more widespread acceptance. We retrospectively analyzed perioperative outcomes of 104 consecutive patients who underwent surgery by this technique between mid-2016 and December 2019, including ostium secundum (67), sinus venosus (34), coronary sinus (1), and ostium primum (1) atrial septal defects and hemianomalous pulmonary venous connection (1). Perioperative variables, surgical times, complications, and follow-up data were analyzed. Patient weight ranged from 6.8 to 41 kg. Incision length ranged from 4 to 6 cm. There was no mortality. All cannulation was central. Difficulty in cannulation (inferior vena cava) was seen in two patients. Morbidity included pneumothorax in 2 (1.9%) patients and subcutaneous emphysema necessitating prolonged intercostal drain retention in 20 (19.2%) patients. Surgical time increased linearly (r = 0.567; P < .001) with increasing patient weight but cardiopulmonary bypass (CPB) time remained unaffected. No chest deformities or paresthesia were noted on follow-up. Scar size decreased in some patients. Right vertical axillary approach can be safely employed to treat simple congenital cardiac lesions with adequate awareness of potential pitfalls. Increasing patient weight increases the surgical time but does not affect CPB times. Incidence of pneumothorax and subcutaneous emphysema is similar to other thoracotomy approaches. It is cosmetically superior.

Pulmonary Echinococcosis Surgery

We present an analysis of the results of surgical treatment of 182 patients with pulmonary echinococcosis (126 patients with uncomplicated and 56 with complicated pulmonary echinococcosis). Of these, only in 23 patients out of 25 planned, it was possible to carry out echinococcectomy purely thoracoscopically through trocar punctures. In 134 cases, videothoracoscopic echinococectomy was performed using a mini-access. In case of bilateral localization of cysts, stage-by-stage operations were performed in 7 patients, and in 3 (36.36%) cases - single-stage echinococcectomy. Echinococcectomy from the lung was performed in 25 patients using a wide thoracotomy approach. In 134 cases, videothoracoscopic echinococectomy was performed using a mini-access. In case of bilateral localization of cysts, stage-by-stage operations were performed in 7 patients, and in 3 (36.36%) cases - single-stage echinococcectomy. Echinococcectomy from the lung was performed in 25 patients using a wide thoracotomy approach. All patients underwent anterolateral thoracotomy. Basically (97.67%) performed organ-preserving operations with the elimination of the residual cavity in the light suture plastics in various modifications. In 2 patients with marginal location and pneumocirrhosis, marginal resection of the lung with an echinococcal cyst was performed.With combined echinococcosis of the lungs and liver, 10 patients were operated on. 6 patients underwent surgical interventions on the lungs and liver through separate approaches at the same time. The use of minimally invasive techniques for pulmonary echinococcosis is possible in more than 2/3 of patients.

Thoracotomy versus sternotomy? The effect of surgical approach on outcomes after left ventricular assist device implantation: Areview of the literature and meta-analysis.

Thoracotomy approaches to left ventricular assist device (LVAD) implantation may reduce surgical morbidity and, through preservation of the pericardial restraint over the right heart, may reduce the incidence of right ventricular failure (RVF). A meta-analysis of all original studies describing the effect of the surgical approach on postoperative outcomes after LVAD implantation was performed. Postoperative outcomes analyzed. Thirteen studies were included with 692 patients undergoing a sternotomy and 373 a thoracotomy approach. Patients undergoing a thoracotomy approach had a higher comorbid status (INTERMACS 1-2: 56% vs. 44%; p = .0004), but were less likely to undergo a concomitant procedure (4% vs. 15%;p = .0002) than patients undergoing a sternotomy approach. Patients undergoing a thoracotomy approach demonstrated a reduced incidence of RVF (OR,.47; CI, .23-.97; p = .04), reexploration for bleeding (OR, .55; CI,.32-.94;p = .03), perioperative blood transfusion (SMD, -.30; CI, -.49 to -.11; p = .002), LOS (-5.57; -10.56 to -.59;p = .03), and mortality (OR,.57; CI,.33-.98;p = .04), but no difference in RVAD requirement or stroke were noted. Metaregression demonstrated that the performance of a concomitant procedure did not modify the effect of the surgical approach on the primary endpoints of RVF or RVAD requirement. In the current meta-analysis including over 1000 patients undergoing LVAD implantation, a thoracotomy approach was associated with a reduced incidence of RVF (but not RVAD requirement), bleeding, LOS, and mortality. No difference in stroke rates was noted. These findings not only offer additional support as to the feasibility of a thoracotomy approach for LVAD implantation but also suggest a potential superiority over a sternotomy approach.

Evaluation of Thoracotomy versus Median Sternotomy Approach in Third-Generation Left Ventricular Assist Device Implantation

<h3>Purpose</h3> The purpose of this study is to compare short term results of patients undergoing a third generation (HVAD™or HeartMate™ 3) Left Ventricular Assist Device (LVAD) implantation through either minimally-invasive, thoracotomy approach or standard median sternotomy. <h3>Methods</h3> We prospectively collected data on all patients at our institution that received an LVAD from September 2008 to February 2020. Surgical approach was decided by the implanting surgeon. We used 1:1 propensity score (PS) matching to compare the sternotomy versus thoracotomy groups. A logistic regression model based on 19 explanatory variables was used to estimate the propensity score. Overall survival post-implantation was summarized using Kaplan-Meier curves and compared using the log-rank test. <h3>Results</h3> A total of 272 patients were included, of whom 194 had sternotomy and 78 had either left thoracotomy and hemi-sternotomy or bilateral thoracotomies. Using PS matching, 128 (64/64) patients were selected. Demographics and operative characteristics were well balanced between groups. Overall, there was a trend towards better survival in thoracotomy group (33.1% vs 66.4%, p=0.06) at 5 years, but higher stroke rate (11% in sternotomy group vs 21% in thoracotomy group, p = 0.035). Following PS-matching, however, there was no difference in early or late mortality (Graph 1) but there was a higher rate of pump exchange in the thoracotomy group (2% vs 9%, p = 0.052). There was no difference in perioperative stroke rates (sternotomy 6% vs thoracotomy 9%), extubation time (2.5 days vs 2.5 days), right ventricular failure (13% vs 14%), renal failure (8% vs 5%) or hospital readmissions (81% vs 88%). <h3>Conclusion</h3> Minimally invasive LVAD implantation is feasible and safe in the current LVAD era. In a PS matched analysis, patients in the minimally invasive group displayed lower overall mortality, but without reaching statistical significance. Adverse events were similar in both groups.

An Analysis of Implant Approach and Impact on Early Outcomes in Real-World Use of the HeartWare™ HVAD™ System

Purpose The HVAD™ System is globally approved for implantation by either a sternotomy or thoracotomy approach, and the small size of the HVAD pump and extended tools available for thoracotomy access have resulted in increasing adoption of the thoracotomy implant approach. The US DT PAS study is the real-world post-approval study of the HVAD System when used in destination therapy patients. APOGEE International is a multinational real-world study of the impact of the implant procedure and patient management on HVAD outcomes. Since these studies allow for either implant approach, data from these two registries will be examined to assess the frequency of various implant approaches and the corresponding outcomes. Methods The objective of this analysis is to examine the frequency of the thoracotomy versus sternotomy implant approaches utilized in the DT PAS and the APOGEE International studies, as well as to describe the outcomes associated with each approach. At the time of presentation, we will have 258 patients with follow-up data through at least 6 months of support. Results Data is currently being collected from 50 centers in the US, EMEA, and Australia. Preliminary data from 143 patients reveals baseline parameters with a mean age 58.7 years, with 16.3% INTERMACS 1 and 44.8 % with ischemic etiology. Approximately one-third of the patients had temporary mechanical support prior to LVAD implant, and 25.9% had previous sternotomies. Implants were performed via a full sternotomy approach in 55.2% of those patients, while 0.7% were converted from thoracotomy to sternotomy, and 44.1% were implanted via a thoracotomy approach (27.3% left lateral thoracotomy (LLT) and upper hemi-sternotomy and 16.8% LLT and right thoracotomy). Data collection and analysis is ongoing, and full baseline and 6-month outcomes will be available for 258 patients at the time of presentation. Conclusion Analyses of real-world use of the HVAD System reveals its increasing use in more complex patients, as well as increasing adoption of the thoracotomy approach.

Evaluation of Pain Management in Patients Undergoing LVAD Therapy via Thoracotomy and Median Sternotomy Approach

<h3>Purpose</h3> Left ventricular assist devices (LVADs) have become a critical component of heart failure therapy. Many efforts are made to reduce complications and hospital length of stay. Thoracotomy and median sternotomy are both used as surgical approaches. Here, we investigated pain level and opioid use in the peri-operative stage in patients undergoing LVAD implantation via thoracotomy or median sternotomy approach. <h3>Methods</h3> : We retrospectively reviewed 55 patients who underwent left ventricular assist device (LVAD) implantation between 2017-2020. Of these, 41 (75%) LVADs were implanted via median sternotomy approach and 14 (25%) LVADs were implanted via thoracotomy. Maximum pain score at day 3 and 7 post-op, at discharge and first follow-up visit were evaluated for both groups. In addition, amount of oxycodone given in the peri-operative period in both groups was investigated. <h3>Results</h3> Both groups were similar in age and gender distribution (Table 1). Heartmate III® was the main VAD type implanted in the sternotomy group (76%; n=31) while HVAD Heartware® was in the thoracotomy group (86%; n=12). There was no difference in the mean length of ICU stay or hospital stay between the groups (both p>0.05; Table 1). While there was a decrease in median pain score from day 3 post-op to first visit follow-up in both groups, the pain score was comparable between the two groups at day 3 and 7 post-op, at discharge and first-follow-up (Table 1). Also, we did not find a significant difference in oxycodone use between thoracotomy and median sternotomy groups. <h3>Conclusion</h3> Both thoracotomy and median sternotomy approach resulted in similar peri-operative pain level and opioid use in patients undergoing LVAD implantation.

Bypassing the Ordinary: A Patient's Unique Journey to Reach His Destination

<h3>Introduction</h3> Advanced heart failure therapies include an armamentarium of mechanical circulatory support (MCS). We present a case for which an array of mechanical support systems were utilized to save a patient. <h3>Case Report</h3> A 71-year old male with HTN, HLD, and smoking history presented with expressive aphasia due to an embolic CVA. Initial workup revealed an ejection fraction <20% with severe global hypokinesis on TEE, and an occluded distal left main and multi-vessel disease by left heart catheterization. Patient underwent a noncomplicated quadruple bypass surgery. Post-operative day #3, he suffered a ventricular fibrillation cardiac arrest and was promptly taken to the OR for emergency IABP insertion followed by central cannulation for VA-ECMO. Post-operative day #4, his pressor requirements increased and a TEE revealed an EF of 5% despite IABP and VA-ECMO support. He was taken back again to the OR for axillary Impella 5.0 implantation and decannulation of VA-ECMO. Over the next couple weeks, he was weaned from pressors, but developed fevers of unknown origin. A CT head revealed a new frontal lobe hematoma in addition to a subacute CVA. He remained neurologically intact, though unable to wean from ventilation. A tracheostomy and PEG tube were inserted. The patient was highly functioning prior to his presentation and wanted everything done including LVAD implantation. A midline sternotomy approach was not suitable due to recent CABG and emergent central cannulation of ECMO; therefore, he underwent Heartmate 3 LVAD implantation via left thoracotomy approach with descending aorta outflow graft cannulation (see Figure 1) as destination therapy. He was discharged to acute rehab post-operative day# 55 and is now home, with tracheostomy and PEG discontinued, and able to walk with limited assistance. <h3>Summary</h3> In cases necessitating various MCS modalities, a left thoracotomy approach with descending aorta outflow graft cannulation for LVAD may be a viable alternative to midline sternotomy.

Comparing HVAD Inflow Cannula Angle between Median Sternotomy and Thoracotomy

<h3>Purpose</h3> Left ventricular assist device (VAD) implantation via thoracotomy is a safe operation with potential advantages compared to conventional sternotomy. One proposed advantage is improved inflow cannula (IFC) positioning due to better visualisation. We investigated the difference in IFC angles for patients with HVADs implanted via these techniques and compared post-operative as well as long term outcomes. <h3>Methods</h3> 42 patients were retrospectively selected from our VAD database. 28 in the sternotomy group and 14 in the thoracotomy group. We included all thoracotomy implants performed at our centre and consecutive sternotomy implants from 2015-2019. Inclusion required a minimum support time of 30 days. Patients with concomitant procedures were excluded. The first post-operative CT chest scan was used to measure the angle between the IFC and mitral valve in axial and coronal planes. <h3>Results</h3> There was no significant difference in gender, INTERMACS score, BMI or age between the two groups. Median support time was not significantly different between the thoracotomy and sternotomy groups (328 vs 360 days, p=0.9). Median cardiopulmonary bypass (CPB) time was higher in the thoracotomy group (104 vs 78 minutes, p<0.01). Median ICU length of stay for the thoracotomy group was 5 days compared to 8 days in the sternotomy group, p=0.08. There was no significant difference in median IFC angle on the axial plane between the thoracotomy group and the sternotomy group (9 degrees v 10 degrees, p=0.3). Similarly, there was no difference in the coronal plane (9 degrees vs 12 degrees, p=0.9). Rates of pump thrombosis, stroke and GI bleeding were not significantly different between the two groups. <h3>Conclusion</h3> In our sample size of 42 patients, the thoracotomy group had a slightly longer CPB time, however, there was no difference in IFC angle, pump thrombosis, GI bleeding, stroke or ICU length of stay. In saying this, there may be other benefits to the thoracotomy approach such as facilitating easier sternal entry upon transplantation.

Splitting the Lungs in a Box for Single Lung Transplantation

Introduction Donor after cardiac death (DCD) are avoided in general for lung transplantation (LTx). Ex-vivo lung perfusion (EVLP) utilizing a TransMedics support device minimizes ischemia-reperfusion injury and helps successful LTx in DCD. Bilateral LTx is usually performed using the support device. We present splitting the lungs in the support device utilizing single LTx in two DCD donors. Case Report Case#1: A 62y Male patient with 40 LAS and h/o IPF underwent single LTx. The donor lungs from a 48y Male with h/o intracranial hemorrhage were procured and placed in the support device. The lungs were transported by air in the device. At the recipient site, the lungs were assessed and split with a GIA stapler in the device. The patient received a single LTx with an anterio-axillary thoracotomy approach. Warm and cold ischemic time were 87 and 103 min. The patient was brought back to the CICU in stable condition and the donor lung functioning well. He spent 5 days in the CICU before being transferred to the floor. His hospital course was complicated post-operatively by primary graft dysfunction, donor derived MSSA, and atrial fibrillation that were managed medically. He was eventually discharged after a 15 day stay. Case#2: Another 72y Male patient with 86 LAS and h/o IPF and PHT underwent single LTx. The donor lungs from a 38y Male, with h/o asphyxiation were procured and placed in the support device for air travel. At the recipient site, the lungs were assessed and split with a GIA stapler in the support device. The recipient underwent cardiac arrest immediately after general anesthesia with epinephrine for PHT. He was intubated, and CPR was started with closed chest compression for 13 min and 4 doses of epi were given. VA ECMO was initiated, and CPR discontinued. A single LTx was completed with an anterio-axillary thoracotomy approach. The warm and cold ischemic times were 173 and 258 min. The patient was brought back to the CICU in stable condition with the decision to continue VA ECMO. Patient was de-cannulated the following day. His hospital course has been extremely complicated and is now on hospital day 34 and on the floor. Summary Our case report on two patients suggests growing acceptance of single LTx in selected patients using EVLP in DCD. This adds to the recent literature that suggests the utility of using EVLP for DCD making more lungs viable and a splitting technique of the lungs in a box may deem appropriate.

Left thoracotomy vs full sternotomy for centrifugal durable LVAD implantation: 1-year outcome comparison post-LVAD and post-heart transplantation.

Left ventricular assist device (LVAD) implantations have traditionally been approached through a full median sternotomy (FS). Recently, a minimally invasive left thoracotomy (LT) approach has been popularized. This study sought to compare the outcomes of FS and LT patients post-primary LVAD implantation and post-subsequent heart transplant (HT). This was a single-center retrospective study. 83 patients who underwent primary centrifugal durable LVAD implantation from January 2014 to June 2018 were included (FS, n = 41; LT, n = 42). 41 patients had a subsequent HT (FS, n = 19; LT, n = 22). Pre-operative patient demographics, intraoperative variables, post-operative 1-year survival, length of hospital stay, complications, and outcomes for LVAD implantation and following HT were analyzed. Intraoperative data showed that the LT group had a 23.4% longer mean LVAD implant surgical time (p < 0.01). One-year post-LVAD survival was similar between the two groups (p = 0.05). Complication rates, with the exception of the rate of hemorrhagic stroke (p = 0.04) post-LVAD implant were similar. One-year survival post-HT was similar between groups (p = 0.35). Complication rates and mean length of hospital stay were also similar (p = 1.0) post-HT. Our study demonstrated that LT approach does not negatively affect post-LVAD implantation or post-HT outcomes. Further, larger studies may determine more detailed effects of LT approach.

Adverse factors and postoperative neuropathic pain in challenging video-assisted thoracoscopic surgery

Whether challenging video-assisted thoracoscopic surgery (VATS) is a minimal invasive surgery remains controversial. This study aimed to analyze causes of challenging conventional multiple-port VATS (CVATS) and conversion to thoracotomy and postoperative pain to provide indications for VATS. This was a two-center retrospective study. Challenging VATS was defined as CVATS with operation time ≥5 hours and it was converted to thoracotomy. This study included patients who were admitted to Joetsu General Hospital (Joetsu, Niigata, Japan) and Toyama University Hospital (Toyama, Japan) for elective CVATS between April 2013 and March 2019. The exclusion criteria were as follows: a planned thoracotomy, uniportal VATS, robot-assisted thoracoscopic surgery, and simultaneous resection of extrathoracic organs. A total of 911 (91.6%) patients underwent CVATS. Of these cases, 876 (96.2%) were suitable VATS cases. On the contrary, 35 cases (3.8%) were recognized as challenging VATS. In 21 (2.3%) cases, VATS took ≥5 hours, and 14 (1.5%) VATS cases were converted to thoracotomy. The causes were severe adhesions (62.9%), air leak (45.7%), body position changes (22.9%), large tumor (14.3%), bronchoplasty or angioplasty (8.6%), and bleeding (2.9%). The minimum diameter of large tumors was 61.4 mm (53-67 mm). In 15 (71.4%) patients, VATS took ≥5 hours, and 10 (71.4%) patients who were converted to thoracotomy developed postoperative neuropathic pain. In this study, VATS ≥5 hours and conversion from VATS to thoracotomy were complicated by postoperative neuropathic pain. In case of bronchoplasty, angioplasty, and large tumor with minimum diameter ≥5 cm, a thoracotomy approach would be appropriate depending on the skill and experience of the surgeon. In cases of local or vascular sheath adhesion, if operation progress is delayed, it may be necessary to set a time limit and decide to convert to thoracotomy, considering patient's safety first.

Minimally invasive (mini-thoracotomy) versus median sternotomy in redo mitral valve surgery: A meta-analysis of observational studies.

Redo mitral valve surgery has traditionally been performed via a median sternotomy. It is often challenging and is associated with increased perioperative mortality. Advances in cardiac surgical techniques over the last two decades have led to an increase in the use of a minimally invasive approach via a right anterolateral mini-thoracotomy as opposed to a repeat median sternotomy. However, despite these advances, there is no general consensus on the best form of entry, and as of yet, there are no randomized controlled trials. We performed a meta-analysis of observational studies to aid in determining the best approach for redo mitral valve surgery. The MEDLINE and EMBASE databases were conducted up until 1 June 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random effects modelling and the I2-test for heterogeneity. Seven retrospective observational studies were included, enrolling a total of 1070 patients. There were a total of 1070 patients. Of these 364 had non-sternotomy approach compared with 707 patients who had median sternotomy. Further subgroup analysis revealed that 327 of the 364 patients had a mini-thoracotomy approach while the remaining 37 patients had a full thoracotomy approach. In-hospital mortality and length of stay were less in non-sternotomy group compared to median sternotomy group. There were no differences in stroke, CPB time and wound infections between the two groups. Redo mitral valve surgery can be performed safely with satisfactory outcomes via a mini-thoracotomy approach. This meta-analysis shows comparable results with reduced in-hospital mortality and hospital length of stay with a mini-thoracotomy approach.