Minimally invasive mitral valve repair using the da Vinci robotic system

BACKGROUND: Minimally invasive mitral valve repair with a shortened hospital stay and quick return to an active lifestyle is the ultimate goal for robotically assisted surgery. We evaluated our da Vinci robotically assisted mitral valve repair experience toward achieving this goal. METHODS: All procedures were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Two ports and a 4-cm intercostal incision in the right chest were used for access. All patients had a ring annuloplasty, and all but 1 had a posterior leaflet resection. The entire repair and all knot tying were performed robotically. RESULTS: Between October 2001 and October 2002, 25 patients (18 men) underwent robotic mitral valve repair. The mean age was 56 years (range, 37 to 81 years). There were no incisional conversions, deaths, strokes, or reoperations for bleeding. Twenty-one (84%) of 25 patients were extubated in the operating room. Overall mean study times were as follows: procedure, 199.7 minutes (range, 140 to 287 minutes); cardiopulmonary bypass, 126.6 minutes (range, 89 to 186 minutes); and cross-clamp, 87.7 minutes (range, 58 to 143 minutes). Eight (32%) patients were discharged home in less than 24 hours, with an average length of stay of 2.7 days. Comparing the first 10 patients to the last 15 there was a significant reduction of times: total operating room time, 318.5 versus 275.1 minutes; cross-clamp, 97.6 versus 81.1 minutes; leaflet resection or repair, 26.2 versus 15.6 minutes; annuloplasty ring, 31.9 versus 24.8 minutes; and length of stay, from 4.2 days to 1.67 days. Five patients had postoperative atrial fibrillation. Two (8%) patients ultimately required mitral valve replacement for recurrent mitral insufficiency. CONCLUSIONS: Mitral valve repair can be successfully performed with the da Vinci robotic system. Long-term follow-up is needed to determine the durability of the repair compared with a standard sternotomy approach.     

Mitral valve repair robotic versus sternotomy.

OBJECTIVE: Robotically assisted mitral valve repair were compared with sternotomy mitral valve repair. Prospectively we evaluated safety and efficacy in performing simple mitral repairs. METHODS: Between February 2004 and September 2005, 25 patients with posterior leaflet insufficiency underwent mitral valve repair using the da Vinci system. They were matched retrospectively with 25 patients who underwent the same repair via a median sternotomy. The minimal invasive repairs were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Repair was performed with two ports and a 4-cm intercostals lateral incision in the right chest for access. All patients had posterior leaflet resection and placement of a ring annuloplasty. RESULTS: All patients had successful valve repairs. There were no deaths. There was one conversion to an extended thoracotomy in the minimal invasive group due to a bleeder on the left atrial appendage. Overall mean study times showed a longer aortic cross-clamp (range, 96.1 min vs 69.6 min) and cardiopulmonary bypass (range, 122.1 min vs 85.7 min) for the minimal invasive group. Length of stay was less for the minimal group (7 days vs 9 days). At postoperative echocardiography two patients in both group developed 2+ mitral regurgitations. All other patients had a competent mitral valve repair with no insufficiency. CONCLUSIONS: Simple mitral valve repair can be successfully performed with the da Vinci robotic system. This approach is as safe as a sternotomy and long-term follow-up is needed to determine the durability of the mini invasive repair.     

机器人二尖瓣成形术的临床应用

目的 总结机器人二尖瓣成形术的临床应用,以评估其安全性及有效性.方法 自2007年1月至2011年4月,对60例患者行机器人二尖瓣成形术,其中男性42例,女性18例;年龄14～70岁,平均年龄(44±13)岁.14例患者术前合并心房颤动.术前心功能(NYHA分级)Ⅰ～Ⅱ级48例,Ⅲ级12例.股动静脉及右侧颈内静脉插管建立心肺转流.于右侧胸壁经肋间插入3个直径为0.8 cm的器械臂,并于第4肋间打1个直径为1.5 cm的工作孔.术者于操作台前、三维成像系统下遥控微创器械完成二尖瓣成形术.术中经食管超声引导建立心肺转流并评估手术效果,术后常规进行随访.结果 平均心肺转流时间(132 ±30)min,主动脉阻断时间(88±22)min.1例患者术后出现重度溶血,再次手术行生物瓣置换后治愈.无手术死亡及中转开放手术.平均随访(16±9)个月,2例患者术后存在轻度反流.结论 达芬奇机器人二尖瓣成形术安全有效,手术效果良好.而且手术视野清晰,结构暴露好,是可供选择的良好微创术式.

Abstract：

Objective To determine the safety and efficacy of robotic mitral valve repair using da Vinci S Surgical system.Method From January 2007 to April 2011,over 400 cases of robotic cardiac surgery have been performed,in which 60 patients with isolated mitral valve insufficiency underwent robotic mitral valve repair,including 42 male and 18 female patients with a mean age of(44 ±13)years(ranging from 14 to 70 years).Forty-eight patients were in NYHA class Ⅰ-Ⅱ and 12 patients in class Ⅲ.Fourteen patients were concomitant with atiral fibrillation.Surgery approach was achieved through 4 right chest ports with femoral perfusion and Chitwood aortic occlusion.Antegrade cold blood cardioplegia was administered directly via chest for myocardial protection.The transesophageal echocardiography was used intraoperatively to estimate the surgical results.Results All patients had successful valve repair including quadrangular resections,sliding plasties and chordal replacement.There was no conversion to median sternotomy.The mean cardiopulmonary bypass and arrested heart time were(132 ±30)min and(88±22)min.One patient had hemolysis after operation,and required mitral valve replacement Echocardiographic follow-up revealed trace to mild regurgitation in 2 patients with a mean of(16±9)months.Conclusion Robotic mitral valve repair is safe and efficacious in the patients with isolated mitral valve insufficiency.     

Technique of aortic valve replacement with the Edwards stentless aortic bioprosthesis 2500.

Aortic valve replacement with a stentless device ought to result in superior hemodynamic function, because obstructing stents and sewing rims are eliminated. From 15 June 1991 to 15 October 1991, 15 patients underwent aortic valve replacement with the newly designed Edwards stentless aortic bioprosthesis 2500. Patients' ages ranged from 51 to 70 years (mean 61 years). Preoperatively 4 patients presented with aortic regurgitation, 7 with aortic stenosis and 4 with combined lesions; 7 patients were male and 8 female. No additional cardiac or noncardiac diseases were encountered. The operations were performed under normothermic extracorporeal cardiopulmonary bypass and cold cardioplegic cardiac arrest. The implanted valves ranged from 21 mm to 27 mm in diameter. Ten patients received a subcoronary implantation with the lower row of stitches made up of interrupted sutures and the upper row of a continuous suture. In 5 patients the so-called miniroot technique was used, also with lower interrupted sutures and running upper sutures, after adaptation of coronary ostia to the performed openings in the graft. Aortic cross-clamp time ranged between 73 min and 94 min (mean 82 min). There was no operative mortality or morbidity. Postoperative echocardiography showed no signs of aortic valve regurgation in any patient and continuous wave-Doppler measurements showed that resting pressure gradients across the aortic valve were absent or low. Our preliminary experiences with a stentless aortic xenograft valve show that in presence of an increased cross-clamp time an improved hemodynamic function will be obtained. Further studies will be needed, however, to establish the long-term behavior of this device.     

Upper mini-sternotomy for aortic valve operations

Objective : To review our experience in using an upper mini-sternotomy approach to aortic valve surgery. Materials and methods : Nineteen consecutive non-selected patients (15 males, mean age 66 years) underwent isolated aortic valve replacement using an upper mini-sternotomy approach. Twelve patients had isolated aortic valve stenosis, four patients had isolated aortic valve incompetence and three patients had mixed aortic valve disease. Results : In all cases, an excellent view of the aortic valve was obtained, aortic valve replacement was performed and no intra-operative difficulties were encountered. Mean aortic cross-clamp time was 83 min and mean cardiopulmonary bypass perfusion time was 97 min. All patients except two were extubated in the operating theatre and there were no major postoperative complications. Mean hospital stay was 4 days. There were no late complications. Conclusions : Aortic valve surgery can be performed, in the conventional manner and using standard surgical instruments, through an upper mini-sternotomy with no alteration to cardiopulmonary bypass or myocardial protection routines.      

Composite stentless valve with graft extension for combined replacement of the aortic valve, root and ascending aorta.

OBJECTIVE: The composite mechanical valve conduit has been most commonly used for patients who require combined aortic valve, root, and ascending aorta replacement, but is limited, especially in the elderly, because of the need for long-term anticoagulation. We report the first consecutive series of patients in whom a composite stentless valve with graft extension, which does not require long-term anticoagulation, was performed. METHODS: Between April 1998 and July 2000, eight patients with severe aortic root and ascending aortic pathology underwent a combined aortic valve, root, and ascending aorta replacement with a Freestyle stentless porcine valve with a Hemashield graft extension. Mean age was 74 (range 56--82), three were males. Concomitant procedures included coronary artery bypass graft (CABG) alone (n=2), mitral valve replacement with atrial septal defect repair (n=1) and CABG with septal myomectomy (n=1). RESULTS: Operative mortality was zero. Median aortic cross-clamp and cardiopulmonary bypass times were 150 and 203 min, respectively. Two patients returned to the operating room for bleeding. Median blood transfusions and hospital length of stay were 4 units and 11 days, respectively. CONCLUSIONS: The composite stentless valve with graft extension is a reasonable alternative to a mechanical valve conduit for patients who require a combined aortic valve, root, and ascending aorta replacement, in whom anticoagulation is not desirable or contraindicated.     

Totally robotic resection of myxoma and atrial septal defect repair

Resection of left atrial myxoma and large atrial septal defect repair were performed in 55 patients using the da Vinci S surgical system to evaluate device safety and efficacy. Fifty-five patients underwent resection of left atrial myxomas (n=10) or secundum-type ASD (n=45) repairs with three cases of concomitant tricuspid valve repairs, using the da Vinci S surgical system. Mean age of the patients was 38+/-12.2 years (range 12-61 years). Cardiopulmonary bypass was achieved peripherally, aortic occlusion was performed with Chitwood cross-clamp, and antegrade cardioplegia was administered via anterior chest. Via four port incisions in the right chest and a 2-2.5-cm working port, all the procedures were completed with the da Vinci robot. All patients had successful resection or repairs. The mean CPB times and aortic cross-clamp times were 108.6+/-12.5 min and 45+/-11.5 min, respectively. There were no operative deaths, strokes, or device-related complications. One patient was reexplored for bleeding. There were no incisional conversions. All the patients were discharged. da Vinci S surgical system has no limitations to safe resection of left atrial myxomas and of ASD repairs, surgical results are excellent, and this technology is of reproducible value with excellent cosmetic results.     

Clinical study of aortic root replacement

From 1990 to 1999, 19 patients underwent aortic root replacement. Annulo-aortic ectasia was observed in 14 patients, aortic dissection in 4, and aortitis in 1. Mean aortic cross-clamp times and cardiopulmonary bypass times were 163 +/- 44 and 247 +/- 99 min, respectively. Concomitant procedures were coronary artery bypass grafting in 3 patients, aortic arch replacement in 1 and aortic arch replacement and elephant trunk method in 2. There were two hospital deaths due to cardiac failure. There was one late death because of pharyngeal cancer 1.7 years after the operation. Seventeen survivors were followed for a mean duration of 4.4 years (0.6-9.3 years). There were no complications during this period. In conclusion, good results were obtained by modified Bentall operation.     

Truly stentless molded autologous pericardial aortic valve prosthesis with single point attached commissures in a sheep model.

OBJECTIVE: Aortic valve cusp extension and free-hand aortic valve replacement with autologous pericardium has been described. The long-term results were shown to be comparable with commercially available aortic bioprostheses. Nevertheless the relatively demanding surgical technique could not find wide acceptance. We developed a new design of a molded aortic valve, fashioned from autologous pericardium, treated briefly with glutaraldehyde, and simplified the implantation technique using single point attached commissures (SPAC). METHODS: Molded autologous valve prostheses were implanted in the subcoronary aortic position in 10 sheep with the commissures connected to the aortic wall at three single commissural points (SPAC). The prosthesis mean size was 21.6+/-1.3 mm and the construction time (excluding 10 min glutaraldehyde treatment) was 6.2+/-1.2 min. Cardiopulmonary bypass and cross-clamp time was 111.1+/-12.4 min and 75.0+/-16.3 min, respectively. Six sheep were euthanized after 201.2+/-10.3 days (6 months) and four sheep were euthanized after 330.8+/-6.5 days (11 months) postoperatively. RESULTS: In all sheep, the valve was immediately competent. At sacrifice, SPAC has proven to be well anchored to the aortic wall and the pericardial valve to be pliable in all cases. The maximum transvalvular gradient after cardiopulmonary bypass and at sacrifice was 3.7+/-2.2 mmHg and 10.6+/-5.2 mmHg, respectively. CONCLUSIONS: This new truly stentless molded autologous aortic valve with simplified implantation technique (SPAC) makes a reliable implantation in a standard timeframe possible. The simplicity of construction, low cost and absent need for anticoagulation of this molded autologous aortic bioprosthesis offers an attractive alternative and not only for patients in the developing world.     

Development and clinical application of minimally invasive cardiac surgery using percutaneous cardiopulmonary support.

OBJECTIVES: Optimal cardiopulmonary support during minimally invasive cardiac surgery remains controversial. We developed cardiopulmonary bypass for minimally invasive cardiac surgery using percutaneous peripheral cannulation. METHODS: Subjects were 34 patients (age: 58 +/- 13 years; range: 17-73) undergoing minimally invasive cardiac surgery using percutaneous cardiopulmonary support between June 1997 and March 1999. Procedures included atrial septal defect closure (n = 14), partial atrioventricular septal defect closure (n = 1), mitral valve replacement (n = 8), mitral valve repair (n = 3), aortic valve replacement (n = 6), coronary artery bypass grafting (n = 1), and right atrial myxoma extirpation (n = 1). Bicaval venous drainage from the right internal jugular vein and the femoral vein and arterial return to the femoral artery were instituted by percutaneous cannulation. Venous drainage was implemented by negative pressure (-20 to -40 mmHg) and arterial return was by conventional roller pump. All procedures were conducted through a skin incision 8 +/- 1 cm, from 6 to 10 cm and partial sternotomy. Aortic cross clamping and cardioplegic solution were administered in the surgical field. RESULTS: The operation lasted 224 +/- 45 min., cardiopulmonary bypass 104 +/- 32 min., and aortic clamping 77 +/- 23 min.. No deaths occurred. One patient with residual atrial septal defect required reoperation through the same skin incision. Only 1 patient required homologous blood transfusion. The average postoperative hospital stay was 15 +/- 5 days. CONCLUSIONS: Minimally invasive cardiac surgery using percutaneous cardiopulmonary support is safe and an excellent option for selected patients affected by single valve lesion, simple cardiac anomalies, and coronary artery bypass grafting.     

Limited upper sternotomy for minimally invasive aortic valve replacement

The practice of minimally invasive valve surgery remains controversial. From May 1998, we began minimal invasive aortic valve replacement through the limited upper sternotomy. This technique is simple and provides and easy approach for the aortic valve. From May 1998 to Jan 2000, we performed 15 cases of aortic valve replacement with the limited upper sternotomy approach. All patients received valve replacement with prosthetic valve. We also described a simple and easy air evacuation system to avoid air embolism, a serious problem with a limited operative field. Mean aortic cross clamping time was 79 min, mean cardiopulmonary bypass time was 106 min, and mean operation time was 207 min. It did not take too much time compared with the conventional approach. Mean extubation time was 62 min and mean bleeding 12 hours after the operation was 96 ml. No patient required blood transfusions. All patients but one walked the very next day after the operation. We believe this new method brings not only cosmetic benefits, but also results in excellent post-operative course.     

Minimally invasive approach for redo mitral valve surgery: a true benefit for the patient

OBJECTIVES: Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. MATERIAL AND METHODS: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59+/-13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. RESULTS: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168+/-73 [redo] vs 168+/-58 min and 52+/-21 [redo] vs 58+/-25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. CONCLUSION: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

机器人微创二尖瓣置换术

目的 总结机器人二尖瓣置换术的临床应用,以评估其安全性及有效性.方法 2008年6月至2011年4月,20例患者接受机器人二尖瓣置换术,男7例,女13例;年龄32～65岁,平均(44.7±9.8)岁.术前心功能Ⅰ～Ⅱ级16例,Ⅲ级4例.15例合并房颤.股动、静脉及右侧颈内静脉插管建立体外循环.右侧胸壁打直径为0.8cm的器械臂孔3个,直径为1.5～2.5cm工作孔1个,术者于三维成像系统下遥控微创器械完成二尖瓣置换.术中食管超声引导建立体外循环并评估手术效果.术后常规进行随访.结果 无手术死亡及术中术式转化.机器人二尖瓣置换平均体外循环(137.1±21.9)min,主动脉阻断(99.3±17.4)min.随访(12.1±6.6)个月,未见瓣周漏等并发症.结论 机器人系统可安全、有效地完成二尖瓣置换,术后近期效果良好.     

Acute dissection of the ascending aorta: first results of emergency valve sparing aortic root reconstruction.

OBJECTIVE: Acute dissection of the ascending aorta requires immediate surgical intervention. In this study, we report our first results with valve sparing aortic root reconstruction removing all the diseased tissues. METHODS: From August 1995 to December 2000, 22 patients with acute aortic dissection of the ascending aorta (Stanford type A) underwent valve sparing aortic root reconstruction. Their ages ranged from 20 to 76 years (52+/-15, 68% males). Dissection was found in the ascending aorta (3 patients) or both in the ascending aorta and aortic arch (19 patients; 86%). Course and length of hospitalization, echocardiographic and clinical follow-up, complications and mortality were analysed. RESULTS: Mean cardiopulmonary bypass time was 212+/-56 min (134-352 min), mean aortic cross clamp time was 157+/-24 min (114-205 min). In patients undergoing additional arch replacement (n=19), circulatory arrest was 35+/-18 min (11-75 min). After reconstruction, intraoperative echocardiography showed aortic insufficiency (AI) grade 0 in 16 patients (84%) and grade 1 in three patients (16%). Stay in intensive care unit was 2.1+/-0.7 days, and postoperative hospitalization was 21+/-14.4 days. There were three perioperative deaths (14%). Mean post-operative follow-up was 18.4+/-18 months (0.4-65.4 month). One patient died 10 months postoperatively. At follow-up, no patient suffered AI grade 2 or higher, and no reoperation for aortic valve failure was necessary. All patients presented with a favorable exercise tolerance being in New York Heart Association functional class I or II. CONCLUSION: Valve sparing aortic root reconstruction in patients with type A dissection can be performed with acceptable intraoperative mortality and morbidity and excellent results during follow-up. The complete resection of the diseased aorta is particularly appealing.     

Effects of Duraflo II heparin-coated cardiopulmonary bypass circuits on the coagulation system, endothelial damage, and cytokine release in patients with cardiac operation employing aprotinin and steroids

The effects of Duraflo II heparin coated cardiopulmonary bypass circuits, low-dose aprotinin, and steroids on the coagulation system, endothelial damage, and cytokine release were evaluated by comparing those treated with low-dose aprotinin and steroids. Twenty-four adult patients undergoing coronary artery bypass grafting, aortic valve replacement, or valve repair surgery were randomly assigned to 2 groups: either heparin-coated (Duraflo group, n = 12) or noncoated equipment (noncoated group, n = 12) groups. In the Duraflo group, the cardiopulmonary reservoir was also coated with heparin. There were no significant differences in age at the time of operation, aortic cross-clamp time, cardiopulmonary bypass time, and rectal temperature during cardiopulmonary bypass. Standard systemic heparinization was performed. Methylpredonisolone and low-dose aprotinin were given in both groups of patients. Serum XIIa factor, TAT, and IL-6 were significantly higher in the control group than in the Duraflo group during cardiopulmonary bypass (p < 0.01). Serum IL-8 was significantly higher in the control group than in the Duraflo group at 24 h after cardiopulmonary bypass (p < 0.05). No significant difference was found in serum thrombomodulin and TNF-alpha; both were within normal during the study period. These results indicate that the use of Duraflo II heparin coated equipment and a heparin-coated cardiopulmonary reservoir suppressed excess coagulation and inflammatory reaction induced by cardiopulmonary bypass.     

非体外循环下全主动脉弓替换术治疗主动脉弓降部动脉瘤的早、中期结果

目的 评价采用常温、非体外循环下全主动脉弓替换手术治疗主动脉弓、降部动脉瘤的术后早、中期结果.方法 2004年4月至11月,对连续7例主动脉弓降部动脉瘤病人实施常温、非体外循环下全主动脉弓替换手术.术后对所有病人进行长期随访,随访截止日期为2011年3月.7例均为男性,年龄23～75岁,中位年龄57岁.真性动脉瘤3例,假性动脉瘤4例,其中1例为弓降部巨大假性动脉瘤覆膜支架置入术失败者.采用胸部正中与左胸前外侧联合切口,全身肝素化后,依次在升主动脉前外侧壁安放主动脉侧壁钳,降主动脉与头臂动脉分别放置主动脉阻断钳,将带四分支人工血管依次与升主动脉行端-侧吻合、与降主动脉及3支头臂动脉行端-端吻合,最后闭合升主动脉残端,切除弓降部主动脉瘤壁.结果 平均胸降主动脉阻断(13.6±5.6)min,左颈总动脉阻断(5.7±0.8)min,无名动脉阻断(7.8±2.5)min,左锁骨下动脉阻断(11.2±1.5)min.术后使用呼吸机平均(12.3±4.1)h.病人全部生存.与同期常温体外循环下主动脉弓替换手术组相比,本组机械通气时间显著减少.无神经系统并发症.术后CT扫描结果显示,主动脉弓降部人工血管形态佳,吻合口周围无渗漏或假性动脉瘤形成.全组平均随访(79.7±2.1)个月,病人生活质量良好,复查CT结果均未见异常.无远期死亡.结论 在常温、非体外循环状态下实施全主动脉弓替换手术,是一种治疗主动脉弓、降部真性或假性动脉瘤的安全、有效的方法,严格把握手术适应证是手术成功的关键.

Abstract：

Objective Study the early and midterm results of a technique-total aortic arch replacement without using extracorporeal circulation or aortic bypass for the treatment of aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta. Methods Between April and November 2004, 7 consecutive patients with true (n = 3) or false (n =4) aortic aneurysm underwent this procedure. The mean follow-up was 6. 6 years. The median age at operation was 57years ( range 23 to 75 years). Normothermia general anesthesia and median sternotomy combined with left anterior thoracotomy were administered. A partially occluding clamp was placed on ascending aorta and a longitude aortic incision was made. Anastomosis of a branched graft to ascending aorta in an end-to-side fashion was commenced. The descending aorta distal to the aneurysm was occluded and transected, and anastomosed to the distal end of the branched graft in an end-to-end fashion. Finally,the arch vessels were divided and anastomosed to the branches of the graft and the aneurysm excised. Results The average cross-clamp time of descending aorta, left common carotid artery, and innominate artery was (13.6 ±5.6)min, (5.7 ±0.8)min, and (7.8±2.5) min respectively. The mean intubation time was (12.3 ±4.1) hours. There were no adverse outcomes or neurologic complications in this series. All patients survived and recovered completely. The mean follow-up time was (79.7 ±2.1) months. All patients lead a normal life. There was no late death. CT follow-up study 6 years after surgery reveals no abnormal image. Conclusion Total aortic arch replacement without cardiopulmonary and aortic bypass is a feasible and effective method for the aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta in selected patients.     

Cardiomyocyte apoptosis and duration of aortic clamping in pig model of open heart surgery.

OBJECTIVE: Apoptotic cardiomyocyte death is induced during open heart surgery, but its determinants are poorly understood. Prolonged aortic clamping time is associated with adverse clinical outcomes. The purpose of this study was to determine whether occurrence of cardiomyocyte apoptosis is related to the duration of aortic clamping in experimental pig model of cardiac surgery with cardiopulmonary bypass. METHODS: The pigs (mean weight 29 +/- 1 kg) were randomly divided to undergo cardioplegic arrest for 60 (n = 4) or 90 (n = 4) min followed by reperfusion period of 120 min. Control group (n = 5) was connected to cardiopulmonary bypass for 120 min without cardioplegic arrest. Cardiomyocyte apoptosis was detected (TUNEL assay and immunohistochemical staining of active caspase-3) in left ventricular tissue samples obtained before ischemia and after the ischemia-reperfusion period. RESULTS: Apoptotic cardiomyocytes were found in all samples obtained after cardioplegic arrest and cardiopulmonary bypass alone with the TUNEL assay. The amount of apoptosis after the 120 min of cardiopulmonary bypass alone in the control group was 0.006 +/- 0.001%. Compared with this, cardiomyocyte apoptosis was increased after cardioplegic arrest. After 60 min of aortic cross-clamp the amount of apoptosis was 0.019 +/- 0.004% (p = 0.031). After 90 min of aortic cross-clamp the amount was 0.042 +/- 0.005% (p < 0.001) being significantly higher than after 60 min (p = 0.001). Aortic cross-clamp of 90 min also resulted in a detectable increase in caspase-3 activation when compared with controls. CONCLUSIONS: The occurrence of cardiomyocyte apoptosis increases with prolonged aortic clamping time during open heart surgery.     

Short-term hemodynamic advantages of stentless CryoLife-O'Brien valve over stented bioprostheses for aortic valve replacement

For the CryoLife-O'Brien valve (CryoLife Inc, Kennesaw, GA, USA), implanted with a single suture line, we aimed to analyze the surgical requests and the hemodynamic results compared to stented bioprostheses. Two groups of patients requiring isolated aortic valve replacement from this population were compared retrospectively: 84 patients receiving the stentless CryoLife-O'Brien valve (Group A) and 94 patients receiving stented bioprostheses (Group B). Preoperative characteristics of patients were statistically equivalent for both groups. Statistically significant differences were observed only for operative durations and post-operative transprosthetic gradients: Aorta cross-clamp and cardio-pulmonary bypass durations were statistically longer for Group A than for Group B (45.9+/-5.7 min vs. 41.1+/-6.8 min; P<0.0001; and 64.3+/-11.6 min vs. 59.3+/-11.9 min, respectively; P=0.0053); maximal gradients and mean gradients were 19.9+/-10.9 mmHg vs. 25.6+/-10.4 mmHg (P=0.0008) and 10.8+/-5.3 mmHg vs. 14.8+/-6.4 mmHg (P<0.0001). Few surgical constraints and early post-operative hemodynamic efficiency of the stentless CryoLife-O'Brien valve means that this bioprosthesis can be intented in current practice for the aortic valve replacement in elderly patients.     

Minimally Invasive Approach for Redo Mitral Valve Surgery: A True Benefit for the Patient

ABSTRACT Objectives Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. Material and Methods: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59 ± 13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. Results: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168 ± 73 [redo] vs 168 ± 58 min and 52 ± 21 [redo] vs 58 ± 25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. Conclusion: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

Placement of a rapid deployment aortic valve in a patient with severely calcified aortic root homograft

Significant aortic calcification is a known sequelae of homograft aortic root replacement and creates a treatment challenge if these patients require cardiac reintervention. The standard surgical option for patients requiring an aortic valve replacement in the setting of a calcified aortic homograft has been a Bentall procedure, which is high-risk with extended cross-clamp, cardiopulmonary bypass and operative times. We present a patient with a severely calcified aortic homograft who underwent successful valve replacement using a rapid deployment aortic valve leaving the aortic root and arch intact and avoiding the more extensive redo aortic root replacement. Similar cases in the literature are rare.