Totally endoscopic aortic valve replacement: technique and first experience

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Van Genechten ◽  
J Claessens ◽  
A Kaya ◽  
A Yilmaz
Keyword(s):  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Blood Loss ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Valve Replacement ◽  
Morbidity And Mortality ◽  
Long Term Results ◽  
Funding Source ◽  
The Mean

Abstract Background Cardiac surgery is still looking for new minimally invasive techniques with less trauma and better cosmetic results. In the field of aortic valve replacement, several types of less invasive procedures were introduced, allowing a reduction in blood loss, infections, ventilation times, morbidity and mortality. The most common technique for minimally invasive aortic valve replacement is the mini-sternotomy approach. In this report, the initial experience with a non-sternotomy approach for aortic valve replacement by means of a totally endoscopic surgical technique is presented. Methods The totally endoscopic aortic valve replacement was carried out in 201 patients (59,7% males, mean age: 71.6±11.7 years) from October 2017 until October 2019. Severe aortic valve stenosis was the surgical indication for all patients, who had a mean EuroSCORE II of 2.35±3.82. The surgery was carried out with the patient in supine position and a standard zero-degree optics was used. A 20 mm working port in the 2nd right intercostal space and two 5 mm trocars gained access to the aorta. After groin cannulation, cardiopulmonary bypass was initiated. Transthoracic aortic cross-clamping followed by antegrade administration of a single shot cold mixed-blood cardioplegia was assessed. The aortotomy was followed by the excision of the stenotic aortic valve and the aortic valve prosthesis was implanted in supra-annular position. After the closure of the aorta, an external pacemaker wire was placed. Results Mean cross-clamp and cardiopulmonary bypass times were 62±14 and 94±25 minutes, respectively. No conversion to a sternotomy was needed. The mean length of stay at the intensive care unit was 69.4±149.6 hours while patients spend 9.6±10 days at the hospital. Due to our new fast track protocol, the mean hospital stay in the last two months was 6.1 days (26 patients, 12.9%). The average postoperative blood loss (24h) was 251±298 mL and the patients were ventilated for 6.9±9 hours. In 10 patients (4.9%), re-exploration in an endoscopic way was needed. None of them had a surgical bleeding focus. No paravalvular leakages were detected at discharge. 69 patients (34.7%) developed atrial fibrillation after surgery. In addition, 10 patients (4.9%) underwent a pacemaker implantation postoperatively whereas 4 patients (1.9%) suffered from a CVA. Finally, the 30-day mortality was 2.0%. Conclusion These results concerning the feasibility and safety of totally endoscopic aortic valve replacement are promising. The aortic cross clamping times are acceptable, and the morbidity and mortality rates are low. Long term results are needed to confirm these initial findings. Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Jessa Hospital

Minimally Invasive Aortic Valve Replacement via Right Anterior Minithoracotomy and Central Aortic Cannulation

2017 ◽  
Vol 12 (2) ◽  
pp. 87-94 ◽  
Author(s):  
Daniel M. Bethencourt ◽  
Jennifer Le ◽  
Gabriela Rodriguez ◽  
Robert W. Kalayjian ◽  
Gregory S. Thomas
Keyword(s):  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Clinical Outcomes ◽  
Valve Replacement ◽  
Aortic Cross Clamp ◽  
Bonferroni Adjustment ◽  
The Mean ◽  
Central Cannulation

Objective This study reports the evolution of a minimally invasive aortic valve replacement (mini-AVR) technique that uses a right anterior minithoracotomy approach with central cannulation, for a 13-year period. This technique has become our standard approach for isolated primary AVR in nearly all patients. Methods This observational study evaluated perioperative clinical outcomes of patients 18 years or older who underwent mini-AVR from November 2003 to June 2015. Results The mini-AVR technique was used in 202 patients during two periods of 2003 to 2009 (n = 65, “early”) and 2010 to 2015 (n = 137, “late”). The mean ± SD age was 72.5 ± 12.9 years and 60% were male. Demographic parameters were statistically similar between the study periods, except for increased body weight in the later period (75.3 ± 14.7 vs 80.9 ± 20.8 kg, P = 0.03). The mean cardiopulmonary bypass and aortic cross-clamp times were significantly different by each year and Bonferroni adjustment, with significant decreases in cardiopulmonary bypass and aortic cross-clamp times beginning 2006. Compared with the early study period, late study period patients were more often extubated intraoperatively (52% vs 12%, P < 0.001), had less frequent prolonged ventilator use postoperatively (6% vs 16%, P = 0.018), required fewer blood transfusions (mean, 2.0 ± 2.3 U vs 3.6 ± 3.0 U; P = 0.011), and had shorter postoperative stay (6.3 ± 4.5 days vs 8.0 ± 5.9 days, P = 0.026). Numerically, fewer postoperative strokes (1% vs 6%, P = 0.09) and fewer reoperations for bleeding (3% vs 6%, P = 0.3) occurred in the late period. In-hospital mortality did not differ (1/65 early vs 3/137 late). Conclusions Overall mini-AVR intraoperative and postoperative clinical outcomes improved for this 13-year experience.

Minimally Invasive Transaortic Repair of the Mitral Valve

2011 ◽  
Vol 14 (4) ◽  
pp. 232 ◽  
Author(s):  
Orlando Santana ◽  
Joseph Lamelas
Keyword(s):  
Mitral Valve ◽  
Aortic Valve ◽  
Mitral Regurgitation ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Valve Replacement ◽  
Operative Mortality ◽  
The Mean ◽  
Transaortic Approach

<p><b>Objective:</b> We retrospectively evaluated the results of an edge-to-edge repair (Alfieri stitch) of the mitral valve performed via a transaortic approach in patients who were undergoing minimally invasive aortic valve replacement.</p><p><b>Methods:</b> From January 2010 to September 2010, 6 patients underwent minimally invasive edge-to-edge repair of the mitral valve via a transaortic approach with concomitant aortic valve replacement. The patients were considered to be candidates for this procedure if they were deemed by the surgeon to be high-risk for a double valve procedure and if on preoperative transesophageal echocardiogram the mitral regurgitation jet originated from the middle portion (A2/P2 segments) of the mitral valve.</p><p><b>Results:</b> There was no operative mortality. Mean cardiopulmonary bypass time was 137 minutes, and mean cross-clamp time was 111 minutes. There was a significant improvement in the mean mitral regurgitation grade, with a mean of 3.8 preoperatively and 0.8 postoperatively. The ejection fraction remained stable, with mean preoperative and postoperative ejection fractions of 43.3% and 47.5%, respectively. Follow-up transthoracic echocardiograms obtained at a mean of 33 days postoperatively (range, 8-108 days) showed no significant worsening of mitral regurgitation.</p><p><b>Conclusion:</b> Transaortic repair of the mitral valve is feasible in patients undergoing minimally invasive aortic valve replacement.</p>

scholarly journals Aortic Bicuspidy: Clinical Profile and Surgery

2021 ◽  
Vol 07 (10) ◽  
Author(s):  
A. Seghrouchni ◽  
Keyword(s):  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Operative Mortality ◽  
Aortic Insufficiency ◽  
Clinical Profile ◽  
Surgical Results ◽  
The Mean ◽  
Outcome Of Surgery

Objective: To study the anatomic-clinical profile of aortic bicuspidy and the outcome of surgery. Patients and Methods: During an 18-year period, 448 patients had aortic valve replacement. Of these, 24 (5.3%) had aortic bicuspidy (AB). The diagnosis of AB was made by echocardiography or during surgery. All patients underwent surgery under extracorporeal circulation. Results: The mean age was 45.2 ± 11.8 years, 14 patients (58.3%) had aortic stenosis and 10 cases (41.7%) had aortic insufficiency, 4 of whom had infective endocarditis. All patients had aortic valve replacement. The operative mortality rate was zero. The mean times of the cardiopulmonary bypass (CPB) and aortic clamping were 99.2 ± 35.4 min and 65.8 ± 24.9 min, respectively. Conclusion: Aortic bicuspidy progresses rapidly and becomes symptomatic in young adults. Despite excellent surgical results, early detection is desirable before complications occur.

Total miniaturized cardiopulmonary bypass: the next step in minimally invasive aortic valve replacement

Perfusion ◽  
2008 ◽  
Vol 23 (5) ◽  
pp. 275-278 ◽  
Author(s):  
I Dimarakis ◽  
D Stefanou ◽  
G Yarham ◽  
J Mulholland ◽  
J Anderson
Keyword(s):  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Valve Replacement ◽  
Initial Experience ◽  
Minimal Incision

Minimally invasive aortic valve replacement has been established in many centres over the last decade. Although numerous modifications have been described to date, these solely involve variations of the utilized operative incision. Total miniaturized cardiopulmonary bypass (tMCPB) offers the theoretical potential of reducing even further the overall procedural “invasiveness”. We describe our initial experience of an application of MCPB for aortic valve replacement through a minimal incision.

Postoperative Plasma Mitochondrial DNA and Cytokine Profiles of Elderly Patients Undergoing Minimally Invasive Aortic Valve Replacement

2019 ◽  
Author(s):  
Maria Serrano-Teruel ◽  
Fernando Fernandez-Rodriguez ◽  
Alberto Bouzas-Mosquera ◽  
Mercedes Fernandez-Moreno ◽  
Paula Dieguez-Garcia ◽  
...  
Keyword(s):  
Mitochondrial Dna ◽  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Elderly Patients ◽  
Valve Replacement ◽  
Plasma Levels ◽  
End Points ◽  
Tnf Α

Introduction Mitochondrial DNA (mtDNA) is gaining increasing interest as a marker of cellular damage and could also act as an inflammatory mediator in cardiopulmonary bypass induced postoperative inflammatory response. Although minimally invasive heart valve surgery reportedly reduces inflammation, the mtDNA and cytokine profile in this context remains unclear. Materials and Methods Here, we report a prospective series of 40 elderly patients with aortic stenosis who underwent bioprosthetic aortic valve replacement (AVR) through upper ministernotomy with either a sutureless (n = 20) or a conventional (n = 20) valve. Primary end points included serial plasma levels of mtDNA (T1: at baseline; T2: 4 hours after surgery; and T3: 24s hour after surgery), cytokines (interleukin-6 [IL-6], tumor necrosis factor-α [TNF-α]), and myocardial necrosis biomarkers (MNBs), whereas secondary end points included clinical and echocardiographic data. Results Significant increases in the postoperative plasma levels (T2) of mtDNA, cytokines, and MNBs were observed in all patients. The postoperative plasma levels of mtDNA, TNF-α, and MNBs showed no significant differences between the treatment groups, although there was a trend toward lower levels in the sutureless group. The decreases in aortic cross-clamp and cardiopulmonary bypass times seen in the sutureless group were associated with significant lower postoperative levels (T2 and T3) of IL-6. Conclusion AVR through upper ministernotomy was associated with a significant increase in postoperative plasma levels of mtDNA and cytokines. There was no difference in the mtDNA levels between the sutureless and conventional valve groups, suggesting a similar level of inflammation in both groups. However, the shorter operation time observed in the sutureless valve group was associated with significantly lower postoperative levels of IL-6, indicating potential clinical benefits.

Concomitant Annular Enlargement in Minimally Invasive Aortic Valve Replacement

2019 ◽  
Vol 14 (2) ◽  
pp. 159-167
Author(s):  
Davida A. Robinson ◽  
Carl A. Johnson ◽  
Ariana M. Goodman ◽  
Peter A. Knight
Keyword(s):  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Length Of Stay ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Valve Replacement ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Aortic Root Enlargement ◽  
Complications Rate

Objective Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient–prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy. Methods Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed. Results Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m2. All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%. Conclusions Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.

Is Transthoracic Minimally Invasive Aortic Valve Replacement Too Time-Consuming for the Busy Cardiac Surgeon?

2011 ◽  
Vol 6 (1) ◽  
pp. 10-14 ◽  
Author(s):  
Mark J. Cunningham ◽  
Christopher E. Berberian ◽  
Vaughn A. Starnes
Keyword(s):  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Learning Curve ◽  
Operating Room ◽  
Valve Replacement ◽  
Learning Curves ◽  
Gradual Improvement ◽  
Surgeon Experience

Objective Transthoracic minimally invasive aortic valve replacement (TMI-AVR) is gaining popularity despite criticism that time from incision to the initiation of cardiopulmonary bypass (exposure time, ET), cardiopulmonary bypass time (CPBT), and cross-clamp time (XCT) is excessive. Database analysis was used to characterize these parameters and their associated learning curves. Methods From 2004 to 2008, 101 patients underwent TMI-AVR at a single institution. Of them, 54 were men (53%) and 47 were women (47%). Mean age was 70 years (range, 24–90 years). ET includes 6-cm incision, second intercostals anterior thoracotomy, medial transection of the third rib, opening pericardial sac, retracing pericardium with stay sutures, placing aortic arterial, and right arterial venous bypass cannulae. ET, CPBT, XCT, and operating room times were calculated. Logarithmic trend analysis established associated learning curves. Results ET steadily improved over time. ET decreased from an average of 51 minutes for the first 25 patients to 39 minutes for the most recent 25 patients. When surgeon experience reached 10 procedures, the ET trend line began to decline steadily and plateaued by 55 cases. Cross-clamp (55 ± 21 minutes), cardiopulmonary bypass (77 ± 31 minutes), and operating room times (304 ± 67 minutes) all remained constant. There were no early deaths or conversions to sternotomy. Conclusions ET learning curve for TMI-AVR was reflected after 10 procedures with continued gradual improvement. Reliability of TMI-AVR was observed in the absence of a learning curve for XCT, CPBT, and operating room times. A sternal-sparing transthoracic approach for AVR can be performed safely, with expected operative times equivalent to sternotomy.

scholarly journals Is aortic valve replacement with a minimally invasive extracorporeal circuit a contemporary option for octogenarians?

2020 ◽  
Vol 31 (1) ◽  
pp. 56-62
Author(s):  
Aschraf El-Essawi ◽  
Marco Follis ◽  
René Brouwer ◽  
Ingo Breitenbach ◽  
Steffen Groeger ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Valve Replacement ◽  
Propensity Score Analysis ◽  
Postoperative Mortality ◽  
Extracorporeal Circuit ◽  
Surgical Aortic Valve Replacement

Abstract OBJECTIVES Minimally invasive extracorporeal circuits have been introduced to cardiac surgery in an attempt to reduce the negative effects of cardiopulmonary bypass on patient outcome. On the other hand, transcatheter aortic valve replacement (TAVR) provides an excellent option to replace the aortic valve without the need for cardiopulmonary bypass. Several studies have compared TAVR to surgical aortic valve replacement (SAVR) but none have utilized a minimally invasive extracorporeal circuit. METHODS We retrospectively analysed the results of both procedures among octogenarians operated in our department from 2003 to 2016. Excluded were patients with an active endocarditis, a history of previous cardiac surgery, as well as those who had a minimally invasive surgical approach. This yielded 81 and 142 octogenarians in the SAVR and TAVR groups, respectively. To compensate for a lack of randomization, we performed a propensity score analysis, which yielded 68 patient pairs for the final analysis. RESULTS The 30-day postoperative mortality was lower in the SAVR group (1.5% vs 5.9%) but not statistically significant (P  = 0.4). In contrast, the incidence of postoperative atrial fibrillation was lower in the TAVR group (13% vs 29%) but also non-significant (P  = 0.2). Finally, the incidence of paravalvular leakage was in favour of the SAVR group (2.9% vs 52%; P  = 0.001) while the transfusion requirement was significantly lower in the TAVR group (29% vs 72%; P &lt; 0.001). CONCLUSIONS SAVR utilizing a minimally invasive extracorporeal circuit improves the quality of patient care and can offer an alternative to TAVR in octogenarians.

Improved Patient Recovery With Minimally Invasive Aortic Valve Surgery: A Propensity-Matched Study

2019 ◽  
Vol 14 (5) ◽  
pp. 419-427 ◽  
Author(s):  
Piergiorgio Bruno ◽  
Federico Cammertoni ◽  
Raphael Rosenhek ◽  
Andrea Mazza ◽  
Natalia Pavone ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Blood Loss ◽  
Aortic Valve Replacement ◽  
Minimally Invasive ◽  
Valve Replacement ◽  
Assisted Ventilation ◽  
Valve Surgery ◽  
Aortic Valve Surgery ◽  
Hospital Stays ◽  
Matched Study

Objective Despite conflicting evidence available, minimally invasive aortic valve replacement (MIAVR) is increasingly used as an alternative to full sternotomy. We sought to compare early outcomes of aortic valve replacement through a full sternotomy (conventional aortic valve replacement [CAVR]) and upper ministernotomy (MIAVR). Methods We analyzed 297 patients having undergone primary, elective, isolated MIAVR or CAVR between January 2014 and June 2018. Following propensity score matching, 120 patients remained in each group. Results MIAVR required longer bypass (93 ± 26 vs 81 ± 24 minutes, P < 0.01) and operative times (214 ± 39 vs 182 ± 37 minutes, P < 0.01). However, aortic cross-clamp times were comparable (57 ± 17 vs 54 ± 14 minutes for MIAVR and CAVR, respectively, P = 0.14). MIAVR had less 24-hour blood loss (253 ± 204 vs 323 ± 296 mL, P = 0.03), less red blood cells transfusions [1.4 packs (1.1 o 1.9) vs 2.1 packs (1.8 to 2.7), P = 0.01], and shorter assisted ventilation time (7.1 ± 3.3 vs 9.7 ± 3.8 hours, P < 0.01) when compared to CAVR. These results led to significantly shorter intensive care unit and hospital stays for MIAVR patients (2.5 ± 1.3 vs 3.4 ± 1.1 days, P < 0.01 and 6.9 ± 4.1 vs 8.2 ± 4.8 days, P = 0.03, respectively). Thirty-day mortality and clinical outcomes did not differ significantly among groups. Conclusions MIAVR through upper ministernotomy was shown to be as safe and reliable as CAVR. Patient recovery time was improved by shortening mechanical ventilation and reducing blood loss and transfusions. These results may be significant for high-risk patients undergoing aortic valve surgery.

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