Ministernotomy for minimally invasive coronary artery bypass grafting

Background Through a ministernotomy ＂J shaped approach, left internal mammary artery （LIMA） bypass grafting to the left anterior descending artery （LAD） can be performed safely off-pump. To achieve a complete revascularization, percutaneous coronary interventions （PCI） with drug eluting stent implantation to other coronary arteries was used. We reported outcomes of the treatment of multivessel coronary artery disease with minimally invasive coronary artery bypass （MICAB） and PCI. Methods Between January 2009 and Dec 2012, 14 patients （11 males, 3 females, mean age was 64.8 _ 10.1 years. Two-vessel disease account for 35.7% （5/14） of these patients, three-vessel disease 64.2% （9/14） （Table 1）. All patients underwent a minimally invasive coronary artery bypass grafting via mini-sternotomy ＂J＂ shaped approach. Seven patients were followed by PCI, 7 for obtuse marginal circumflex, 5 for right coronary artery （RCA）. Angiographic assessment of graft patency was performed in all patients during the PCI procedure. The clinical follow-up period lasts from 11-24 months. Results The in-hospital mortality was 0%. There was neither conversion to a full median sternotomy nor intraoperative complications. Ventilation time was 6.6 ＋_ 4.1 h. Blood loss ranged 341 ＋_ 78.8 mL. ICU stay ranged 22.3 _ 12.8 h. Hospital postoperative stay lasted for 6.5 ＋ 1.6 days. Prior to PCI patients showed 100% patent left internal mammary artery. One patient had mediastinitis （Tables 2-3）. Rate of freedom from cardiac reintervention during the follow-up period was 92.8% （13/14）. Conclusions The inferior J-shaped sternotomy is simple, reproducible, and the safest technique for performing minimally invasive coronary bypass surgery. MICAB ＋ PCI is also safe, feasible and efficacious.     

Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery

ObjectivesMinisternotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.MethodsThe data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).ResultsAfter propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan–Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).ConclusionsMinimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.     

经胸骨小切口主动脉根部置换术

目的比较经胸骨小切口主动脉根部置换术与经传统切口手术的临床结果。方法1999年7月至2001年10月行。Bentall手术60例。采用胸骨小切口15例，传统胸骨正中切口45例。结果两组病例均无围手术期死亡。术后早期并发症发生率两组间差异无显著性(P=0．661)。小切口组的手术时间及体外循环时间长于传统切口组(P=0．027，P=0．015)。小切口组的机械通气时间、输血量、未输库存血率、胸腔引流量及总住院时间均优于传统切口组，但差异无显著性。结论经小切口的Bentall手术，不增加手术风险。胸骨上段小切口适用于Bentall手术及部分弓置换术，胸骨下段小切口适用于心脏巨大或同期行心内畸形的矫治者。     

Minimally invasive coronary artery bypass grafting via a lower ministernotomy for left anterior descending artery myocardial bridging: mid-term results

Open in a separate window OBJECTIVESCoronary artery bypass grafting or supra-arterial myotomy is now suggested as a better therapeutic option in myocardial bridging (MB) when medical treatment fails to control symptoms. For left anterior descending (LAD) MB, minimally invasive coronary artery bypass via a lower ministernotomy can be offered.METHODSForty-four consecutive patients who underwent elective minimally invasive coronary artery bypass surgery from 2005 to 2014 via an inferior sternotomy using the left internal mammary artery as a bypass graft for LAD MB were evaluated retrospectively.RESULTSThe mean age was 59.1 ± 13.1 years with 26 (59%) men and 18 (41%) women. The mean body mass index was 27.2 ± 3.9 and the mean EuroSCORE II was 1.6 ± 1.8. Routine coronary multislice computed tomography angiography on the 6th postoperative day revealed 97.7% graft patency. During the initial hospital stay, 1 patient (2.3%) underwent a reoperation for early graft failure. Forty patients (91%) could be followed up for a mean period of 64.4 ± 24.5 months after the procedure, during which 2 patients (4.5%) died of non-cardiac causes and 9 patients (20.5%) underwent postoperative coronary angiography with confirmed graft occlusion in only 1 case (2.3%). The improvement in the distribution of patients in the Canadian Cardiovascular Society class 0 was from 4 patients (9%) preoperatively to 37 patients (84%) at the end of the follow-up period (P-value 0.001).CONCLUSIONSMinimally invasive coronary artery bypass surgery via a lower ministernotomy may be safe and efficient for treating LAD artery MB with acceptable complication rates, cosmetic benefits and patency rates.     

胸骨下段小切口心脏不停跳心内直视手术587例

目的：探讨胸骨下段小切口联合心脏不停跳微创技术在心内直视手术中应用效果。方法：1999年10月至2008年9月,采用胸骨下段小切口联合心脏不停跳微创技术行心内直视手术共587例。其中各种先天性心脏病459例,风湿性心脏瓣膜病128例。结果：全组患者顺利完成不停跳手术。体外循环时间（78．13±18．52）min,上、下腔静脉阻断时间（61．21±16．51）min,呼吸机辅助时间（12．01±8．83）h。术后并发血红蛋白尿21例、低心排血综合症11例、呼吸道感染5例、灌注肺3例。住院死亡13例,死亡原因为低心排血综合症4例,肺动脉高压危象2例,室颤2例,肾功能衰竭、心脏压塞、脑部气体栓塞、感染性心内膜炎及呼吸衰竭各1例。随访2～108月,发现有3mm以下的室间隔缺损残余分流3例,二尖瓣置换术后抗凝不当脑栓塞2例,无晚期死亡。结论：胸骨下段小切口联合心脏不停跳技术,可安全、有效地应用于大多数心内直视手术,既有外科微创和外表美观的优点,又有良好的心肌保护效果。     

正中小切口全胸骨劈开术治疗心脏疾病的手术策略及应用技巧

目的:探讨正中小切口全胸骨劈开术应用于多数心脏手术策略和实施技巧。方法:总结2017年11月至2019年12月复旦大学附属中山医院302例全胸骨劈开正中小切口心脏直视手术经验,与常规正中切口手术和右侧开胸微创手术的二尖瓣修复手术的手术效果、手术时间、主动脉阻断时间、出血量和ICU停留时间进行比较。结果:正中小切口手术将胸骨全切开,但将常规的20 cm切口长度缩小到6～8 cm,胸骨只撑开6 cm,可进行多数心脏手术,取得良好效果,适应证广,且具备微创手术切口小、美观的优点,对胸廓影响小,又具备正中开胸的心脏显露清楚,手术迅速确切,心脏中心插管,手术安全性高,不增加手术时间、主动脉阻断时间、出血量和ICU停留时间,不需要单肺通气等诸多优势。结论:正中小切口这种微创手术方式,适应证广泛,操作较方便,易于临床推广。     

Minimally invasive aortic valve surgery

Since their introduction, it has been demonstrated that minimally invasive aortic valve replacement (MIAVR) approaches are safe and effective for the treatment of aortic valve diseases. To date, the main advantage of these approaches is represented by the reduced surgical trauma, with a subsequent reduced complication rate and faster recovery. This makes such approaches an appealing choice also for frail patients [obese, aged, chronic obstructive pulmonary disease (COPD)]. The standardization of the minimally invasive techniques, together with the implementation of preoperative workup and anesthesiological intra- and post-operative care, led to an amelioration of surgical results and reduction of surgical times. Moreover, the improvement of surgical technology and the introduction of new devices such as sutureless and rapid deployment (SURD) valves, has helped the achievement of comparable results to traditional surgery. However, transcatheter technologies are nowadays more and more important in the treatment of aortic valve disease, also in low risk patients. For this reason surgeons should put new efforts for further reducing the surgical trauma in the future, even taking inspiration from other disciplines. In this review, we aim to present a review of literature evidences regarding minimally invasive treatment of aortic diseases, also reflecting our personal experience with MIAVR techniques. This review could represent a tool for a well-structured patient assessment and preoperative planning, in order to safely carrying out an MIAVR procedure with satisfactory outcomes.     

影响胸骨小切口瓣膜替换术因素的探讨

目的探讨胸骨正中中下段小切口(胸骨小切口)瓣膜替换术中影响术野显露及手术操作的因素.方法35例接受胸骨小切口瓣膜替换手术,包括23例二尖瓣替换(MVR)和12例二尖瓣和主动脉瓣双瓣替换(BVR),其中男19例,女16例,年龄为21～62(44±9)岁,分析患者胸廓和心脏形态特征对主动脉阻断时间(ACT)和体外循环时间(CPBT)的影响.结果左室舒张末内径在60mm以上时,MVR的主动脉阻断时间(ACT)(p=0.009)和体外循环时间(CPBT)(p＜0.003)明显延长,但BVR的ACT(p=0.023)和CPBT(P=0.022)明显缩短.胸骨柄上缘平第五胸椎以下时,MVR和BVR的ACT和CPBT均罗平第四胸椎以上者延长,但差异不显著.主动脉结的高低、心胸比值、左房内径和主动脉窦内径对ACT和CPBT均无影响.结论左心室扩大及胸骨柄位置较低可能影响胸骨小切口瓣膜替换术的术野显露及手术操作.