Comparison of outcomes of minimally invasive mitral valve surgery for posterior, anterior and bileaflet prolapse

Objective: We sought to compare the outcomes of minimally invasive mitral valve (MV) surgery for anterior (anterior mitral leaflet, AML), posterior (posterior mitral leaflet, PML) or bileaflet (BL) MV prolapse. Methods: Between August 1999 and December 2007, 1230 patients who presented with isolated AML (n = 156, 12.7%), isolated PML (n = 672, 54.6%) or BL (n = 402, 32.7%) MV prolapse underwent minimally invasive MV surgery. The preoperative mitral regurgitation (MR) grade was 3.3 ± 0.8, left ventricular ejection fraction (LVEF) was 62 ± 12% and mean age was 58.9 ± 13.0 years; 836 patients (68.0%) were male. Mean follow-up time was 2.7 ± 2.1 years, and the follow-up was 100% complete. Results: Overall, the MV repair rate was 94.0% (1156 patients). Seventy-four patients (6.0%) received MV replacement. MV repair for PML prolapse was accomplished in 651 patients (96.9%), for AML in 142 patients (91%) and for BL in 363 patients (90.3%). Repair techniques consisted predominantly of leaflet resection and/or implantation of neochordae, combined with ring annuloplasty. Concomitant procedures were tricuspid valve surgery (n = 56), atrial fibrillation ablation (n = 286) and closure of an atrial septal defect or patent foramen ovale (PFO) (n = 89). The overall duration of cardiopulmonary bypass was 127 ± 40 min and aortic cross-clamp time was 78 ± 33 min. The mean postoperative hospital stay was 11.6 ± 9.7 days for the overall group. Early echocardiographic follow-up revealed excellent valve function in the vast majority of patients, regardless of the repair technique, with a mean MR grade of 0.3 ± 0.5. For the overall group, 5-year survival rate was 87.3% (95% CI: 83.9–90.1) and 5-year freedom from cardiac reoperation rate was 95.6% (95% CI: 94.1–96.7). The log-rank test revealed no significant difference between the three groups regarding long-term survival or freedom from reoperation. Conclusions: Minimally invasive MV repair can be achieved with excellent results. Long-term outcomes and reoperation rates for AML prolapse are not significantly different from PML or BL prolapse.     

Del Nido cardioplegia for minimally invasive aortic valve replacement

Background

We analyzed the impact and safety of del Nido Cardioplegia (DNC) in patients undergoing minimally invasive aortic valve replacement (MIAVR).

Methods

We analyzed all isolated MIAVR replacements from 5/2013‐6/2015 excluding re‐operative patients. The approach was a hemi‐median sternotomy in all patients. Patients were divided into two cohorts, those who received 4:1 crystalloid:blood DNC solution and those in whom standard 1:4 Buckberg‐based cardioplegia (WBC) was used. One‐to‐one propensity case matching of DNC to WBC was performed based on standard risk factors and differences between groups were analyzed using chi‐square and non‐parametric methods.

Results

MIAVR was performed in 181 patients; DNC was used in 59 and WBC in 122. Case matching resulted in 59 patients per cohort. DNC was associated with reduced re‐dosing (5/59 (8.5%) versus 39/59 (61.0%), P < 0.001) and less total cardioplegia volume (1290 ± 347 mL vs 2284 ± 828 mL, P < 0.001). Antegrade cardioplegia alone was used in 89.8% (53/59) of DNC patients versus 33.9% (20/59) of WBC patients (P < 0.001). Median bypass and aortic cross‐clamp times were similar. Clinical outcomes were similar with respect to post‐operative hematocrit, transfusion requirements, need for inotropic/pressor support, duration of intensive care unit stay, re‐intubation, length of stay, new onset atrial fibrillation, and mortality.

Conclusions

Del Nido cardioplegia usage during MIAVR minimized re‐dosing and the need for retrograde delivery. Patient safety was not compromised with this technique in this group of low‐risk patients undergoing MIAVR.     

Development of a high-fidelity minimally invasive mitral valve surgery simulator

Objectives

The aim of this study was to develop a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator.

Patient-reported outcome measures after mitral valve repair: a comparison between minimally invasive and sternotomy

OBJECTIVESTo compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair.Open in a separate windowMETHODSWe included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: ‘Recovery Time’, ‘Postoperative Pain’ (at day 2 and 1, 3, 6 and 12 weeks) and ‘Treatment Satisfaction’. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores.RESULTSThe response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8–62.1) vs MI 61.7 (43.1–73.9), P = 0.03] and Pain [ST 65.7 (40.1–83.1) vs MI 79.1 (65.5–89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5–100) vs MI 100 (95.0–100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7–18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7–14.5, P = 0.03) was MI surgery.CONCLUSIONSMI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar.     

Comparison of limited and full sternotomy in aortic valve replacement

Objective: The practice of minimally invasive valve surgery remains controversial. The aim of this study was to evaluate the technical feasibility and postoperative course of aortic valve replacement through limited upper sternotomy compared to conventional full sternotomy. Methods: From May 1998 to August 2000, we performed 24 cases of isolated aortic valve replacements through the limited upper sternotomy approach (group M). During the same period, 18 patients received isolated aortic valve replacements through the conventional full sternotomy approach (group C). Operation duration, postoperative course and laboratory data were compared between the two groups. Results: All patients received a valve replacement with a prosthetic valve. There was no significant difference between the two groups in mean aortic cross-clamping time, mean cardiopulmonary bypass time or mean operation duration (skin to skin). No patient required blood transfusion. Patients in the group M were extubated earlier, with less postoperative blood loss and discharged earlier after the operation than those in group C. On the first postoperative day, the peak level of lactic acid dehydrogenease was significantly lower in the group M than those in group C. Conclusion: Limited upper sternotomy for aortic valve replacement resulted in shorter operation duration and minimized operative risks for the patients. We believe this method brings not only cosmetic benefits but also improved postoperative course.     

微创手术与传统开放手术治疗脊柱转移癌的效果比较

目的 比较微创手术与传统开放手术治疗脊柱转移癌的临床疗效.方法 2017年12月—2019年6月,海军军医大学长征医院收治胸腰椎转移癌患者72例,采用随机数字表法分为2组,其中36例采用微创手术治疗(微创组),36例采用传统开放手术治疗(开放组).采用疼痛视觉模拟量表(VAS)评分评估患者疼痛缓解情况,采用Franke...     

右胸小切口二尖瓣置换术与传统手术比较

目的 比较右胸小切口与胸骨正中切口二尖瓣置换术的临床疗效.方法 回顾性分析2009年9月至2012年5月行右胸小切口二尖瓣置换术128例(微创组)与同期行胸骨正中切口二尖瓣置换术120例(传统组)的临床资料,并进行对比研究.结果 两组在年龄、性别、心功能分级、瓣膜病变、合并心脏疾病等方面的差异无统计学意义(P＞0.05);两组术后并发症(再次开胸止血、新发房颤、肺炎、脑血管意外、伤口愈合不良等)发生率差异亦无统计学意义(P＞0.05).围术期微创组死亡1例,传统组死亡2例.微创组的体外循环、主动脉阻断时间较传统组长(P＜0.05),而术后ICU住院、术后机械通气、术后住院时间较传统组短(P＜0.05),术后引流量及输血量也较传统组少(P＜0.05).术后微创组随访(15.0±4.8)个月,传统组(23.3±3.9)个月.两组均无院外死亡病例,无瓣周漏、脑血管意外、机械瓣故障、溶血等严重并发症发生,两组心功能分级差异无统计学意义(P＞0.05).结论 右胸小切口二尖瓣置换手术安全、有效,值得临床推广应用.     

微创主动脉瓣置换术及术后早期结果

目的 探讨微创主动脉瓣置换术的可行性及效果.方法 回顾性分析2010年6月至2011年10月,20例单纯微创主动脉瓣置换术,男12例,女8例;平均年龄(47.60±12.28)岁.患者采用双腔气管插管,股动、静脉插管建立体外循环,右胸骨旁第3肋间切口,腋前线第4肋间置入阻断钳阻断升主动脉,完成主动脉瓣置换术.结果 全组无死亡,1例因主动脉吻合口出血转为前正中开胸行升主动脉置换术,所有患者均顺利出院.19例微创主动脉瓣置换术患者平均体外循环(124.00±39.83)min,主动脉阻断(97.21±33.17) min,气管插管(13.55±3.87)h,术后ICU停留(16.34±3.82)h,术后平均住院(6.63±1.45)天.未输血患者13例.平均切口长度(4.73±0.54)cm.术后复查无瓣周漏,无瓣膜功能障碍.电话或门诊随访,l例因脑梗塞死亡,余19例均恢复良好,没有瓣周漏,心功能Ⅰ级.结论 采用股动、静脉插管技术建立体外循环,右胸第3肋间微小切口完成微创主动脉瓣置换术,手术创伤小,术后恢复快,出血、输血少,美容效果好,安全可靠,值得推广.     

Superior trans‐septal approach for minimally invasive mitral valve surgery via right small thoracotomy

Minimally invasive mitral valve surgery (MIMVS), despite its challenges, is not a rare procedure. However, MIMVS via a right small thoracotomy must be performed using long‐shafted surgical instruments and thoracotomy instruments specialized for minimally invasive cardiac surgeries. We have performed 12 cases of MIMVS via right small thoracotomy using the superior trans‐septal approach and secured a surgical visual field that easily allows a finger to reach the mitral valve annulus without using special instruments for minimally invasive cardiac surgery. We named this technique the “drawer‐case technique.” In conclusion, MIMVS via right thoracotomy using the superior trans‐septal approach can be performed easily and safely, similar to mitral valve surgery performed via median sternotomy.