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.     

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.     

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.     

Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results

BACKGROUND: This study compares intermediate-term outcomes of mitral valve reconstruction after either the standard sternotomy approach or the new minimally invasive approach. Although minimally invasive mitral valve operations appear to offer certain advantages, such as reduced postoperative discomfort and decreased postoperative recovery time, the intermediate-term functional and echocardiographic efficacy has not yet been documented. METHODS: From May 1996 to February 1999, 100 consecutive patients underwent primary mitral reconstruction through a minimally invasive right anterior thoracotomy and peripheral cardiopulmonary bypass and Port-Access technology (Heartport, Inc, Redwood City, Calif). Outcomes were compared with those for our previous 100 patients undergoing primary mitral repair who were operated on with the standard sternotomy approach. RESULTS: Although patients were similar in age, the patients undergoing the minimally invasive approach had a lower preoperative New York Heart Association classification (2.1 +/- 0.5 vs 2.6 +/- 0.6, P <.001). There was one (1.0%) hospital mortality with the sternotomy approach and no such case with the minimally invasive approach. Follow-up revealed that residual mitral insufficiency was similar between the minimally invasive and sternotomy approaches (0.79 +/- 0.06 vs 0.77 +/- 0.06, P =.89, 0- to 3-point scale); likewise, the cumulative freedom from reoperation was not significantly different (94.4% vs 96.8%, P =.38). Follow-up New York Heart Association functional class was significantly better in the patients undergoing the minimally invasive approach (1.5 +/- 0.05 vs 1.2 +/- 0.05, P <.01). CONCLUSIONS: These findings demonstrate comparable 1-year follow-up results after minimally invasive mitral valve reconstruction. Both echocardiographic results and New York Heart Association functional improvements were compatible with results achieved with the standard sternotomy approach. The minimally invasive approach for mitral valve reconstruction provides equally durable results with marked advantages for the patient and should be more widely adopted.     

Minimally invasive "pocket incision" aortic valve surgery.

A minimally invasive approach to aortic valve surgery through a transverse incision ("pocket incision") at the right second intercostal space was examined. Sixteen patients with a mean age of 30 years underwent this approach. The third costal cartilage was either excised (n = 5) or dislocated (n = 11). The right internal mammary artery was preserved. Cardiopulmonary bypass (CPB) was established with aortic-right atrial cannulation in all except the first case. Aortic valve replacements (AVR) were performed in 15 patients and one had aortic valve repair with concomitant ventricular septal defect closure. There was no mortality and no major complications. The aortic cross-clamp, CPB and operative times were 72 +/- 19 mins, 105 +/- 26 mins and 3 hrs 00 min +/- 29 mins respectively. The mean time to extubation was 5.7 +/- 4.0 hrs, ICU stay of 27 +/- 9 hrs and postoperative hospital stay of 5.1 +/- 1.2 days. Minimally invasive "pocket incision" aortic valve surgery is technically feasible and safe. It has the advantages of central cannulation for CPB, preservation of the internal mammary artery and avoiding sternotomy. This approach is cosmetically acceptable and allows rapid patient recovery.     

Minimally invasive mitral valve surgery through right anterolateral minithoracotomy.

BACKGROUND: This study evaluates the feasibility of minimally invasive mitral valve surgery. The aim of the study was to minimize surgical access to achieve better cosmetic results, less postoperative discomfort, and faster recovery. METHODS: From September 1997 to October 1998, 76 patients underwent mitral valve surgery through a right anterolateral minithoracotomy at the fourth intercostal space. The mitral valve was either repaired (n = 21) or replaced (n = 55). In all cases, open femoral artery-femoral vein cannulation was used for cardiopulmonary bypass. In 27 cases, an endoluminal aortic clamp was used, but in 49 cases, the aorta was cross-clamped with a transthoracic, sliding-rod-design clamp. RESULTS: There were no approach-related limitations to surgical intervention. Intraoperative transesophageal echocardiography revealed excellent results after valve repair and no paravalvular leak in any patient after mitral valve replacement. Mean duration of intensive care and postoperative hospital stay was 32+/-5.2 hours and 7+/-1.1 days, respectively. There were no major complications related to femoral vessel cannulation. In 1 patient, transient neurological problems developed, with subsequent complete recovery. There was one hospital mortality (85-year-old male patient died of upper GI bleeding). CONCLUSIONS: Minimally invasive port access mitral valve surgery can accelerate recovery and decrease pain, while maintaining overall surgical efficacy. It also provides better cosmetic results to our patients, and now it has become our standard approach for isolated mitral valve surgery.     

Perfusion during coronary and mitral valve surgery utilizing minimally invasive Port-Access technology

Minimally invasive surgery has been used in the treatment of some cardiovascular diseases. Port-Access surgery is a new minimally invasive technique that utilizes cardiopulmonary by-pass and a specialized catheter system that provides cardiopulmonary support and myocardial preservation. Extrathoracic cardiopulmonary support is established with femero-femoral bypass with kinetic assisted venous drainage. An endovascular catheter system allows for all the benefits of mechanical support as well as myocardial preservation. This catheter system includes an endoaortic balloon catheter which functions as an aortic cross clamp and antegrade cardioplegia delivery catheter, endopulmonary vent, and endocoronary sinus catheter used for administration of retrograde cardioplegia. An initial cohort of 20 patients was treated by the Port-Access surgical approach with cardiopulmonary bypass. Ten patients had coronary artery surgery and 10 patients had mitral valve surgery. The average bypass times were 94.4 min (coronary artery) and 152.8 min (mitral valve). The mean aortic occlusion times were 49.7 min (coronary artery) and 112.6 min (mitral valve). All patients were weaned from bypass. This initial patient series demonstrated that Port-Access surgery was feasible in selected patients.     

Anterolateral right thoracotomy for mitral valve procedure after previous coronary artery bypass grafting with functioning internal mammary artery grafts

AIM: Mitral valve procedure after previous coronary artery bypass grafting (CABG) with functioning internal mammary artery (IMA) grafts has high risk. Especially, internal mammary artery grafts injury may be fatal. The anterolateral right thoracotomy affords easy access to the right atrium with minimal dissection, and minimizes the risk of injury to the IMA grafts. We reviewed our operative technique and outcome after mitral valve procedure after previous CABG with functioning IMA grafts. METHODS: Thirteen patients (11 male and 2 female, mean age of 67.7+/-8.5 years, range 54 to 80 years) underwent mitral valve replacement after previous CABG with functioning IMA grafts from march 1993 to september 2002. The mean interval between the previous CABG and the mitral valve procedure was 3.8 years (range 9 months to 8 years). Four patients had simultaneous mitral valve procedures at initial CABG (2 repairs and 2 replacements). The operation has performed through the anterolateral right thoracotomy, under ventricular fibrillation with moderate hypothermia and without cardioplesia. RESULTS: Mitral valve repair was performed in 3 patients, mitral valve replacement in 10 patients. The mean coronary bypass time was 69.1+/-16.2 min (range 45 to 98 min). The operation time was 159.3+/-29.4 min (range 120 to 219 min). Intensive care unit stay days was 1.9+/-1.6 days (range 1 to 5 days). Peak CK/CK-MB values were 555.1+/-290.4 IU/16.6+/-10.7 IU (range 176 to 924 IU/7 to 44 IU). Peak troponin I value was 9.5+/-5.2 pg/mL (range 4 to 17.8 pg/mL). There was no IMA injury and no early death. Other complications were newly arrhythmia in 3 patients, renal insufficiency in 1 patient, reoperation for bleeding in 1 patient. CONCLUSIONS: Anterolateral right thoracotomy approach, ventricular fibrillation with moderate hypothermia without cardioplesia were a safe and good method for mitral valve operation after previous CABG with functioning IMA graft.     

Endovascular balloon versus transthoracic aortic clamping for minimally invasive mitral valve surgery: impact on cerebral microemboli

To evaluate micro embolic events occurrence during minimally invasive mitral valve procedures, comparing balloon endovascular aortic occlusion (Group I) and transthoracic aortic clamping technique (Group II), 36 patients (20 in Group I and 16 in Group II) undergoing minimally invasive mitral valve surgery were selected by CT scan and Doppler studies for absence of atherosclerotic disease at aortic, coronary or peripheral level. Assignment to one of the two groups was made on the basis of surgeon's preference. Continuous automated intra-operative transcranial Doppler was used to monitor micro embolic events during five operative steps: cardiopulmonary bypass (CPB) setup, time interval from CPB start until aortic clamp positioning, first minute after clamp-on, first minute after clamp-off, first ten minutes after CPB weaning start. More embolic events were observed in Group II than in Group I (total 143.4+/-30.6 per patient vs. 78.9+/-28.6 per patient). A large amount of embolic events occurring mainly when the aortic clamp was positioned and released accounted for the observed differences. In a low risk population for embolic events occurrence, endovascular balloon aortic clamping determined less embolic signals than transthoracic aortic clamping.     

Video-assisted Port-Access surgery for radical myxoma resection

The curative treatment of choice for myxomas is surgical removal. Most of the patients are young and active and are focused on postoperative comfort, cosmesis and a fast track to complete rehabilitation, all of which is related to the degree of invasiveness of the intervention. We report our first experience with video-assisted Port-Access surgery for atrial myxoma. From February 1997 until April 2000, nine patients (3M/6F)) had an atrial myxoma resection with the Heartport Endo-CPB and Endo-aortic clamp system. Mean age was 54 +/- 21.9 years. Most of the patients were symptomatic and had good LV function. Two patients had a combined procedure: one mitral valve replacement and one vascular shunt for dialysis. Mean aortic cross clamp time was 69 +/- 32.8 min and mean perfusion time was 103 +/- 42.7 min. There were no conversions to sternotomy. Three patients had minor complications. Mean ICU and hospital stay were 1 +/- 1.4 and 6 +/- 3.9 days respectively. No thromboembolic or peripheral ischaemic complications were observed. There were no hospital deaths. No recurrent tumors have been identified. The Port-Access approach for myxoma resection constitutes a invaluable alternative to sternotomy with the same gold standards of results and quality.     

Minimally invasive video-assisted mitral valve surgery: from Port-Access towards a totally endoscopic procedure

Right thoracotomy is an alternative to mid-sternotomy for left atrium access. The Port-Access approach is an option that reduces the skin incision and obviates rib spreading. PATIENTS AND METHODS: From February 1997 until November 1999, 121 patients underwent mitral valve surgery through a right antero-lateral thoracotomy using the Heartport cardiopulmonary bypass (CPB) system. Mean age was 60 years (31-84). Most patients had normal ejection fractions and were in NYHA Class II or III. Seventy-five patients had valve repair (62%) and 46 (38%) had valve replacement. Pathologies were myxoid (n = 80), rheumatic (n = 30), chronic endocarditis (n = 5), annular dilatation (n = 3), sclerotic (n = 1), ingrowing myxoma (n = 1), and one closure of a paravalvular leak. RESULTS: Two patients had conversion to sternotomy for aortic dissection (one died) with the Endo-Aortic Clamp, and two others for peripheral vascular problems. One patient died at postoperative day 1 after reoperation for failed repair, another with double valve surgery on postoperative day 4 after two revisions for bleeding. Twelve underwent revision for bleeding (10%). Three had prolonged ICU stay for respiratory insufficiency. Two late valve replacements for endocarditis occurred. Echographic control revealed residual insufficiencies (grade 1-2) in two valvular repairs. There were neither paravalvular leaks nor myocardial infarcts. There were no cerebrovascular accidents due to embolic phenomena. Mean ICU and hospital stay were 2.1 and 8.7 days, with a major difference between the first 30 patients and those who followed. CONCLUSION: Port-Access mitral valve surgery can be a valid alternative to conventional sternotomy and seems to be an important improvement in minimally invasive cardiac surgery.     

Three-year follow-up after port-access mitral valve surgery

INTRODUCTION: After the promising early results with Port-Access mitral valve (MV) surgery, the mid-term results were evaluated. METHODS: Among 31 patients receiving this surgery, there were two subgroups (A and B). The 14 patients in group A (7 men, 7 women, 64.0 +/- 12.8 years, LVEF 0.62 +/- 0.118) received the procedure exactly as proposed by Heartport. The 17 patients in group B (6 men, 11 women, 63.0 +/- 11.48 years, LVEF 0.61 +/- 0.117) received a modified technique for a less complex procedure. The underlying diseases were MV insufficiency (n = 14), MV stenosis (n = 9), and combined MV disease (n = 8). One female patient had a partial atrial ventricular canal. RESULTS: Perioperative mortality was 3.2%. Survival at 39.0 +/- 6.3 months (median +/- SEM) was 93.5%. Two patients required intraoperative inotropic and mechanical support (intra-aortic balloon pump [IABP]). One of these two patients died on postoperative day 3 due to low cardiac output syndrome. All ther patients survived the procedure. Twenty-four patients underwent MV replacement, 7 patients received MV repair, and 1 patient received, in addition, ASD repair. In group B, operative time, ICU stay, and hospitalization was shorter. CONCLUSIONS: Good early results after Port-Access MV surgery were confirmed by equal mid-term results. The patients are satisfied with the surgical and the cosmetic results, however, Port-Access MV surgery still has to prove superior outcome compared to conventional MV surgery. In selected cases a true reduction of the surgical trauma is possible.     

Repair of Atrial Septal Defects via Limited Right Anterolateral Thoracotomy

Introduction: Right thoracotomy is a well known alternative for median sternotomy to gain access to the right atrium. The Port-Access? technique is a surgical option to reduce the skin incision to 5 cm and have a considerable gain in cosmesis and post-operative rehabilitation.

Patients and methods: From February 1997 to May 2000, 50 patients (19M/31F) had Port-Access? atrial septal defect repair (ASD) with the Heartport® Endo-CPB and Endo-aortic clamp system. Mean age was 46 years (range10.5–74 years). Forty nine patients had a type II ASD. Most of the patients were asymptomatic (48 were NYHA class I-II). Five patients underwent combined procedures: two mitral valve repairs, one mitral valve replacement, one plasty of the superior vena cava and one mini Cox-Maze. Direct closure was obtained in 34 patients (68%). Mean aortic cross clamp time was 56 minutes (range 24–134 min) and mean perfusion time was 102 minutes (range 32–196 min). Results: There were no conversions to sternotomy. The procedure was complicated in six patients: revision for bleeding (n = 1), stenting of the iliac vein (n = 1), enlargement plasty of the femoral artery (n = 1), transient renal failure (n = 1), sick sinus syndrome requiring pacemaker implantation (n = 1) and one lymphocoele. No thromboembolic or peripheral ischaemic complications were noted. Per-and postoperative echocardiography showed no leakage in any patients. There was no hospital mortality. Mean ICU and hospital stay were 1.14 days (range 1–3 days) and 6.41 days (range 4-10 days) respectively.

Conclusion: The Port-Access? approach of ASD closure constitutes a valid alternative to sternotomy with the same standards of results and quality.     

The edge-to-edge technique as a trick to rescue an imperfect mitral valve repair.

OBJECTIVE: The edge-to-edge (E-to-E) technique in mitral valve repair (MVR) is promising especially to correct mitral insufficiency (MI) caused by complex mitral valve lesions. We tested this technique to improve residual MI straight after conventional MVR. METHODS: From September 1998 to January 2002, 108 consecutive patients underwent MVR with current techniques for pure MI. Intraoperative transesophageal echocardiography was performed before and after MVR. At the end of cardiopulmonary bypass (CPB), 11 patients presented residual mitral regurgitant jet area (MRA) > or =2.0 cm(2). The E-to-E technique was used to improve this residual MI, without taking-down the original MVR. RESULTS: There were no hospital deaths. One patient died of non-valve-related cardiac death about 6 months after hospital discharge. At intraoperative ecocardiography, residual MRA improved from 3.0 +/- 0.8 cm(2), after conventional MVR, to 0.7 +/- 0.9 cm(2), after the E-to-E technique (P = 0.00014). Additional CPB time of 14.9 +/- 2.8 min was needed. These echocardiographic results were confirmed at follow-up of 13.8 +/- 8.1 months. CONCLUSIONS: The E-to-E technique is a simple, rapid, effective, and durable option to reduce residual MI and rescue an imperfect conventional MVR.     

Intraoperative treatment of chronic atrial fibrillation with ultrasound

AIM: The purpose of this retrospective study is to evaluate the efficacy of intraoperative atrial compartmentalization utilizing ultrasound (US) energy in selected patients with chronic atrial fibrillation (CAF). METHODS: From March 1999 to June 2000, 27 patients with ages ranging from 15 to 69 (mean 44.62+/-15.61 years), 15 of whom were female, underwent intraoperative atrial compartmentalization with US. Mitral valve replacement was performed in 22 patients, mitral valve repair in 4 and 1 patient with paroxysmal atrial fibrillation (AF) underwent isolated atrial compartmentalization. The compartmentalization procedure was started using an ultrasonic device (UltraCision) at the level of the right atrium on cardiopulmonary bypass (CPB) and with beating heart, and then, after the mitral valve procedure, the ablation-lines were traced in an inverted U-shape, involving the 4 pulmonary veins. All patients were given verapamil or amiodarone for electrical atrial remodeling for 6 months. RESULTS: Time of surgery was 166 min on average, that is approximately 79 min of CPB, 59 min of aortic crossclamping, 12.5 min for right atrial lesion lines and 14 min for the left ones. After weaning CPB, all the patients maintained adequate cardiac output. Immediate reversion to sinus rhythm was achieved in 24 patients (88.8%). A small intraoperative left atrial wall rupture due to the ablation technique was easily repaired by a direct continuous suture. Another complication observed in 1 patient was a sternal instability, which was fixed successfully. Two patients died because of postoperative respiratory failure due to bilateral pneumonia in 1 case and low cardiac output, complicated by septicemia. The pharmacological anti-arrhythmic treatment was stopped 6 months after surgery. During 29 months of follow-up, 20 patients (74%) were still in sinus rhythm. CONCLUSIONS: The use of US during mitral valve operation in patients with CAF allowed for easy and rapid reestablishment of the sinus rhythm. This technique modifies and makes the Maze procedure easier, decreases surgical time and the incidence of postoperative complications.     

Port-Access mitral valve surgery: summary of results

BACKGROUND: The purpose of this study was to review the short-term results of an initial experience with minimally invasive cardiac valve surgery using the Port-Access approach in terms of feasibility, safety, and reproducibility. METHODS: Between October 1995 and October 1997, 151 minimally invasive cardiac valve procedures were performed at our institution using the Port-Access approach. The patients' mean age was 58.1 years (range 21 to 91 years) and 50% were male. Aortic valve replacement was performed in 35 (23.2%) patients, mitral valve repair in 56 (37.1%) patients, mitral valve replacement in 36 (23.8%) patients, and complex valve procedures in 24 (15.9%) patients. RESULTS: The operative mortality rate for isolated mitral valve surgery was 1.1% (1/92) and for all mitral valve surgery 3.5% (4/113). The operative mortality rate for isolated aortic valve patients was 5.7% (2/35). For the total group the operating mortality was 4% (6/151). Early complications for mitral valve patients included reoperation for bleeding or tamponade in 5 (4.4%) patients, myocardial infarction in 2 (1.2%) patients, and transient ischemic attack and wound infection in 1 (0.1%) patient each. One patient required reoperation for mitral valve failure that resulted in aortic dissection unrelated to the Endoaortic Clamp catheter and ultimately led to death. Two (5.6%) aortic valve patients required reoperation for bleeding and two (5.6%) required reoperation for tamponade. CONCLUSIONS: Minimally invasive Port-Access techniques can be applied to most patients with valvular heart disease with minimal morbidity and mortality and good postoperative valve function and may be the preferred approach for isolated mitral and aortic valve surgery.     

Correction of simple congenital heart defects in infants and children through a minithoracotomy.

BACKGROUND: Minimally invasive surgical techniques in pediatric cardiac surgery have evolved throughout the last 10 years. Advantages of minimally invasive procedures include excellent cosmetic results and superior postoperative outcome. However, safety of minimally invasive techniques has to be proven. METHODS: In 21 female infants and children, a right anterolateral thoracotomy was performed. Mean age was 7.1 years (0.5 to 16.6 years) and mean body weight was 20.8 kg (8.3 to 56 kg). The following defects were repaired: atrial septum defect type II (n = 14); partial atrioventricular septum defect (n = 3); partial anomalous pulmonary venous connection (n = 2); ventricular septum defect (n = 2); mitral valve insufficiency (n = 1); and resection of an embolized atrial septum defect occluder (n = 1). In two cases, aortic cross-clamping was performed by using a transthoracic clamp. In 5 patients, femoral cannulation was performed. Skin incisions were limited to 4 to 7 cm. RESULTS: There was no operative or late mortality. Mean operation time, bypass time, and aortic cross-clamp time were 138 (95 to 275), 72 (32 to 179), and 35 (12 to 120) minutes, respectively. Mean postoperative mechanical ventilation time, mean intensive care unit stay, and mean hospital stay were 3.9 hours (1 to 12 hours), 1.4 days (1 to 3 days), and 12 days (8 to 18 days), respectively. Postoperative complications included hemorrhage in 1 patient requiring surgical intervention. Mean follow-up period was 13.3 months (1 to 36 months). All patients were in New York Heart Association class I postoperatively. Trivial mitral insufficiency was evident in 1 patient operated for partial atrioventricular septum defect. CONCLUSIONS: A small right anterolateral thoracotomy as a minimally invasive technique in pediatric cardiac surgery is a safe and suitable alternative in the operative management of simple congenital heart defects. Cosmetic results are superior, however, improved postoperative outcome has to be proven.     

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.     

The preferable use of port access surgical technique for right and left atrial procedures

We analyzed the results of mitral valve operations, either alone or in any combination with the tricuspid valve surgeries in the period from January 2001 till June 2004. The period was divided into two parts, classical sternotomy part (C) (110 patients) and minimally invasive port access part (PA) (105 patients), later being used from December 2002 till now. Also, what we were interested in was the total hospital cost of both types of the procedures and if there are any advantages of port access over the classical sternotomy. The mean age was 61.2 +/- 10.2 and 60.3 +/- 12.4 (C versus PA) and mean additive Euroscore was 6.5 versus 4.8 (C versus PA). There were statistically significant differences (P < .0001) in cardiopulmonary bypass time (CPB) and aortic cross-clamp time (AXT) between both groups: CPB C versus PA: 98.3 +/- 33.5 minutes versus 149.2 +/- 44.2 minutes (mean +/- sd), AXT C versus PA: 62.9 +/- 20.6 minutes versus 88.3 +/- 26.8 minutes (mean +/- sd). There were no statistically significant differences in mortality and stroke for both the groups (mortality P = 1, stroke P = .53). There were statistically significant differences in favor of the port access over the classical one for: intensive unit stay (P = .004), postoperative stay in days (P < .0001), blood transfusion (P < .0001), postoperative thoracic bleeding (P < .0001), and extubation time in hours (P < .0001). Furthermore, costs analyses showed that the average total patient cost was less for port access (P < .0005). The differences between endo and classical type suggested that the port access type of surgery is 20% cheaper than the classical one. We may conclude that port access surgery is an acceptable alternative to classical type of surgery, also in complex pathology of the mitral and tricuspid valve.     

Myocardial protection in operations requiring more than 2 h of aortic cross-clamping.

OBJECTIVE: Long periods of aortic cross-clamping time during cardiac surgery are associated with high rates of morbidity and mortality because of damage to the myocardium. Recently, we have used a method of myocardial protection based on the principles of hyperkalemic cardioplegic arrest. We use antegrade administration of warm, undiluted blood followed by continuous retrograde infusion of tepid, undiluted blood supplemented with potassium and magnesium. In this study, we have retrospectively reviewed our experience with this method of cardioprotection in operations requiring more than 2 h of cross-clamp time. METHODS: We retrospectively reviewed the medical records of 1280 patients who underwent myocardial revascularization, valve repair or replacement, or a combination of both operations between January 1, 1994 and December 31, 1997. Patients were divided into two groups: the short cross-clamp group (SXC) (n = 1144) had cross-clamp times < 120 min (mean, 78 +/- 20 min; range, 35-119 min) and the long cross-clamp group (LXC) (n = 136) had cross-clamp times > 120 min (mean, 154 +/- 31 min; range, 120-277 min). We compared preoperative, operative, and postoperative variables between the two groups. RESULTS: Significantly more patients in the long cross-clamp group (43.4%) underwent the combined operation than in the short cross-clamp group (2.3%), and the rate of reoperation was significantly higher in the long cross-clamp group (12%) than in the short cross-clamp group (5%). Despite these differences in operative complexity, we found no difference in hospital mortality rates between the two groups. The only significant postoperative differences were that the long cross-clamp group had a greater need for inotropic agents (43 vs. 29%), higher serum levels of creatine kinase (880 +/- 583 vs. 613 +/- 418) and CK-MB (10.9 +/- 6.4 vs. 5.9 +/- 5.2), and a longer hospital stay (9.6 vs. 6.1 days). CONCLUSION: Long, complex operations requiring more than 2 h of cross-clamping can be performed safely with our method of cardioprotection based on continuous retrograde infusion of tepid, hyperkalemic, undiluted blood.