Simulation of a Right Anterior Thoracotomy Access for Aortic Valve Replacement Using a 3D Printed Model

Objective The right anterior lateral thoracotomy (RALT) approach for aortic valve replacement provides excellent outcomes in expert hands while avoiding sternal disruption. It, however, remains a technically demanding niche operation. Instrument trajectories via this access are influenced by patient anatomy, the intercostal space chosen, and surgical retraction maneuvers. Methods To simulate the typical surgical maneuvers, on an anatomically accurate model, and to measure the instrument trajectories, we generated a 3-dimensional (3D) printed model of the heart and chest cavity. A simulated approach to the base of the right coronary sinus via the medial-second intercostal, the lateral-second intercostal, or third intercostal space was made. Keeping the instrument in place, 3D scans of the models and geometrical measurements of the instrument trajectories were performed. Results The 3D scans of the 3D printed model showed a high fidelity when compared to the original computed tomographic scan image geometry (mean deviation of 1.26 ± 1.27mm). The instrument intrathoracic distance was 75 mm via the medial-second, 115 mm via the lateral-second, and 80 mm via the third intercostal space. The 3D angulation of the instrument to the incision was 33.77o, 55.93o, and 38.4o respectively. The distance of the instrument to the lateral margin was 12, 26, and 5 mm respectively. The cranial margin of the incision was always a limiting margin for the instrument. Conclusions Three-dimensional printing and 3D scanning facilitated a realistic simulation of the instrument trajectory during RALT approach. The lateral-second intercostal approach showed the most favorable approach angle and distance from the lateral margin, although it also had the longest intrathoracic distance.

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Totally endoscopic aortic valve replacement via an anterolateral approach using a standard prosthesis

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivz287 ◽

2019 ◽

Vol 30 (3) ◽

pp. 424-430 ◽

Cited By ~ 3

Author(s):

Masayoshi Tokoro ◽

Sadanari Sawaki ◽

Takahiro Ozeki ◽

Mamoru Orii ◽

Akihiko Usui ◽

...

Keyword(s):

Mitral Valve ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Operating Time ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Intercostal Space ◽

Anterolateral Approach ◽

The Right

Abstract OBJECTIVES Totally endoscopic aortic valve replacement (AVR) is still a challenging operation, and only a few series reports exist in the literature. The purposes of this study were to establish a method for endoscopic AVR and evaluate its initial results. METHODS A total of 47 patients (median age 76 years, 17 men) underwent endoscopic AVR. The main wound was created in the right anterolateral 4th intercostal space through a 4-cm skin incision. No rib spreader was used. A 3-dimensional endoscope was inserted at the midaxillary line. A 5.5-mm trocar was inserted in the 3rd intercostal space, thus creating a 3-port setting similar to that used for endoscopic mitral valve surgery. A standard prosthesis was used, and the sutures were tied using a knot pusher. Results were compared with those of 157 patients who underwent right transaxillary AVR with direct vision plus endoscopic assist. RESULTS Patient backgrounds did not differ significantly between the 2 groups. No deaths occurred in the entire series. There was no conversion to thoracotomy or sternotomy in the endoscopic AVR group. The complication rate did not differ significantly between the 2 groups. The total operating time was significantly shorter in endoscopic AVR (188–206 min); the cardiopulmonary bypass time (130–128 min) and the cross-clamp time (90–95 min) did not differ significantly (median, endoscopic AVR, right transaxillary AVR). Two patients underwent endoscopic double-valve (aortic and mitral) surgery under the same conditions. CONCLUSIONS Endoscopic AVR was possible through 3 ports created in the right anterolateral chest, similar to the procedure for endoscopic mitral valve surgery. By adopting a common approach for both the aortic and the mitral valve operations, endoscopic double-valve surgery can be performed seamlessly.

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Aortic Annular Sizing Using Novel Software in Three-Dimensional Transesophageal Echocardiography for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Diagnostics ◽

10.3390/diagnostics11050751 ◽

2021 ◽

Vol 11 (5) ◽

pp. 751

Author(s):

Chanrith Mork ◽

Minjie Wei ◽

Weixi Jiang ◽

Jianli Ren ◽

Haitao Ran

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Transesophageal Echocardiography ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Meta Analysis ◽

Three Dimensional ◽

Minimum Diameter ◽

Transcatheter Aortic Valve ◽

Mean Differences

(1) Background: We performed this study to evaluate the agreement between novel automated software of three-dimensional transesophageal echocardiography (3D-TEE) and multidetector computed tomography (MDCT) for aortic annular measurements of preprocedural transcatheter aortic valve replacement (TAVR); (2) Methods: PubMed, EMBASE, Web of Science, and Cochrane Library (Wiley) databases were systematically searched for studies that compared 3D-TEE and MDCT as the reference standard for aortic annular measurement of the following parameters: annular area, annular perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter. Meta-analytic methods were utilized to determine the pooled correlations and mean differences between 3D-TEE and MDCT. Heterogeneity and publication bias were also assessed. Meta-regression analyses were performed based on the potential factors affecting the correlation of aortic annular area; (3) Results: A total of 889 patients from 10 studies were included in the meta-analysis. Pooled correlation coefficients between 3D-TEE and MDCT of annulus area, perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter measurements were strong 0.89 (95% CI: 0.84–0.92), 0.88 (95% CI: 0.83–0.92), 0.87 (95% CI: 0.77–0.93), 0.87 (95% CI: 0.77–0.93), 0.79 (95% CI: 0.64–0.87), and 0.75 (95% CI: 0.61–0.84) (Overall p < 0.0001), respectively. Pooled mean differences between 3D-TEE and MDCT of annulus area, perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter measurements were −20.01 mm2 ((95% CI: −35.37 to −0.64), p = 0.011), −2.31 mm ((95% CI: −3.31 to −1.31), p < 0.0001), −0.22 mm ((95% CI: −0.73 to 0.29), p = 0.40), −0.47 mm ((95% CI: −1.06 to 0.12), p = 0.12), −1.36 mm ((95% CI: −2.43 to −0.30), p = 0.012), and 0.31 mm ((95% CI: −0.15 to 0.77), p = 0.18), respectively. There were no statistically significant associations with the baseline patient characteristics of sex, age, left ventricular ejection fraction, mean transaortic gradient, and aortic valve area to the correlation between 3D-TEE and MDCT for aortic annular area sizing; (4) Conclusions: The present study implies that 3D-TEE using novel software tools, automatically analysis, is feasible to MDCT for annulus sizing in clinical practice.

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