Individualized strategy of minimally invasive cardiac surgery in congenital cardiac septal defects

Background Intracardiac septal defect is repaired using median sternotomy in most centers; however, there are several reports using minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect. Methods In this study, 472 patients who underwent minimally invasive repair of intracardiac septal defects (atrial septal defect, (ASD), ventricular septal defect, (VSD), and atrioventricular septal defect, (AVSD)) from January 2012 to June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups: the right sub-axillary vertical incision (RSAVI) group (N = 335, including192 ASDs, 135 VSDs and 8 AVSDs); the right anterolateral thoracotomy (RALT) group (N = 132, including 77 ASDs, 51 VSDs and 4 AVSDs); and the left anterolateral thoracotomy (LALT) group (N = 5, all subpulmonary VSDs). Results Concomitant surgeries included nine cases of right ventricular outflow tract obstruction relief, nine cases of mitral repairs and 37 cases of tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (two residual VSD shunts and one mitral regurgitation). The age and body weight of the RSAVI group were significantly lower than those of the RALT and LALT groups (all P < 0.01). No postoperative death was observed. Postoperative complications included one case of chest exploration for bleeding, one case of reoperation due to patch dehiscence during the same admission, one case of transient neural dysfunction, three cases of diaphragmatic paresis and 13 cases of atelectasis. The median stay in the intensive care unit was two days, while the median postoperative hospitalization duration was six days. The echocardiography results before discharge indicated no significant residual lesions. No reoperation, no new onset of chest deformities and no sclerosis were observed during the follow-up. Conclusions Intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. RSAVI is suitable in infants and children, while RALT is more commonly used in adolescents and adults. LALT is an alternative incision to repair subpulmonary VSD.

All we need to know about internal thoracic artery harvesting and preparation for myocardial revascularization: a systematic review

Internal thoracic arteries (ITAs) are the gold standard conduits for coronary revascularization because of their long-term patency and anti-atherosclerotic properties. Harvesting and preparation of ITAs for revascularization is a technically demanding procedure with multiple challenges. Over the last few decades, various methods and techniques for ITAs harvesting have been introduced by different surgeons and applied in clinical practice with different results. Harvesting of ITAs in pedicled or skeletonized fashion, with electrocautery or harmonic scalpel, with open or intact pleura, with clipping the end or keeping it perfused; papaverine delivery with intraluminal injection, perivascular injection, injecting into endothoracic fascia, and papaverine topical spray are the different techniques introduced by the number of researchers. At the same time, access to the ITAs for harvesting has also been studied. Access and harvesting through median sternotomy, mini anterolateral thoracotomy, thoracoscopic, and robotic-assisted harvesting of ITAs are the different techniques used in clinical practice. However, the single standard method for harvesting and preparation of ITAs has yet to be determined. In this review article, we aimed to discuss and analyze all these techniques of harvesting and preparing ITAs with the help of literature to find the best way for ITAs harvesting and preparation for myocardial revascularization.

Demographic and Surgical Profile of the Patients Underwent Minimally Invasive Cardiac Surgery in a Rural Center of Bangladesh

Background: Ever Since its inception , minimally invasive cardiac surgery is growing rapidly for better convenience and superb post operative outcome. As newer instruments, surgical technique and operative exposure are increasing more and more patients are demanding minimally invasive cardiac surgery. Objective: The study was conducted to evaluate the various pre operative and peroperative factors in minimally invasive cardiac surgery. Materials and Methods: A retrospective observational study on the patients who underwent minimally invasive cardiac surgery in the department of cardiovascular and thoracic surgery, Khwaja Yunus Ali Medical College, Sirajganj, Bangladesh from January 2016 to December 2020. Results: A total of 40 cases were operated through minimally invasive cardiac surgery in our department. Maximum number of cases was Atrial septal defect(ASD), and minimally invasive direct coronary artery bypass (MIDCAB). About 62.50% were female, majority of patients were in the range of 11-15 years. Right anterolateral thoracotomy was done in 27 cases and left anterolateral thoracotomy in 10 cases. The maximum number of cannulation done in femoral artery and femoral vein, followed by direct superior vena caval cannulation and only a single percutaneous superior venacaval cannulation through internal jugular vein. In 14 cases the length of incision was in the range of 3-4 cm and 12 cases in 4-5cm. Conclusion: Minimally invasive cardiac surgery is now becoming more demanding. As more and more centers are opening the door to newer technology, common people are also becoming conscious about its excellent post operative outcome. KYAMC Journal.2021;12(02): 71-74

Right Anterolateral Thoracotomy Versus Sternotomy for Resection of Benign Atrial Masses: A Systematic Review and Meta-Analysis

Objective Primary benign cardiac tumors are rare disease entity that predominantly originate from the atria. Benign masses can induce heart failure, arrhythmia, or thromboembolic events. Therefore, surgical excision is often indicated. Current guidelines on the preferred approaches for resection (i.e., median sternotomy [MST] or right anterolateral thoracotomy [RAT]) are lacking. The aim of the current meta-analysis was to evaluate all studies comparing RAT to MST for excision of benign atrial masses in terms of safety, efficacy, and complications. Methods The PubMed and EMBASE databases were searched through 9 June 2020. Data regarding mortality, complications, recurrence, ICU stay, and length of hospital stay were extracted and submitted to meta-analysis using random effects modelling. Heterogeneity was assessed by the I 2 test. Results Four retrospective observational studies were included, including 196 patients (RAT n = 97, MST n = 99). Mortality was 0% in both groups. Recurrence was <1% in the RAT group and 0% in the MST group. Complication rate tended to be lower in favor of the RAT group. Furthermore, RAT was associated with lower length of ICU stay (−17.7 hr, P = 0.01) and hospital stay (−4.0 days, P < 0.001). No significant differences in cardiopulmonary bypass ( P = 0.09) and cross-clamp times ( P = 0.15) were observed. Conclusions The RAT approach is as safe and effective as MST for the excision of benign atrial masses. Moreover, RAT is associated with a reduced complication rate and a reduced duration of hospitalization and could be considered as the preferred approach in anatomically suitable patients.

Off-Pump Aortic Bypass for Hypoplastic Arch and Aortic Coarctation Via Anterolateral Thoracotomy

We report the case of a 21-year-old woman who was referred with uncontrolled hypertension. Computed tomography angiography revealed aortic arch hypoplasia and severe aortic coarctation. An off-pump ascending-to-descending aortic bypass surgery using synthetic graft was performed via left anterolateral thoracotomy. The patient recovered well and was discharged home uneventfully after five days. This procedure was performed without touching the head vessels or any collateral vessels. We consider this a safe and less invasive alternative technique for adult coarctation patients who have aortic hypoplasia or interrupted aorta.

Pulmonary Echinococcosis Surgery

We present an analysis of the results of surgical treatment of 182 patients with pulmonary echinococcosis (126 patients with uncomplicated and 56 with complicated pulmonary echinococcosis). Of these, only in 23 patients out of 25 planned, it was possible to carry out echinococcectomy purely thoracoscopically through trocar punctures. In 134 cases, videothoracoscopic echinococectomy was performed using a mini-access. In case of bilateral localization of cysts, stage-by-stage operations were performed in 7 patients, and in 3 (36.36%) cases - single-stage echinococcectomy. Echinococcectomy from the lung was performed in 25 patients using a wide thoracotomy approach. In 134 cases, videothoracoscopic echinococectomy was performed using a mini-access. In case of bilateral localization of cysts, stage-by-stage operations were performed in 7 patients, and in 3 (36.36%) cases - single-stage echinococcectomy. Echinococcectomy from the lung was performed in 25 patients using a wide thoracotomy approach. All patients underwent anterolateral thoracotomy. Basically (97.67%) performed organ-preserving operations with the elimination of the residual cavity in the light suture plastics in various modifications. In 2 patients with marginal location and pneumocirrhosis, marginal resection of the lung with an echinococcal cyst was performed.With combined echinococcosis of the lungs and liver, 10 patients were operated on. 6 patients underwent surgical interventions on the lungs and liver through separate approaches at the same time. The use of minimally invasive techniques for pulmonary echinococcosis is possible in more than 2/3 of patients.

Individualized Strategy of Minimally Invasive Cardiac Surgery in Congenital Cardiac Septal Defects

Background: Intracardiac septal defect tends to be repaired by minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect. Methods: Four hundred and seventy-two patients who underwent minimally invasive repair of intracardiac septal defects (Atrial septal defect, ASD; ventricular septal defect, VSD; atrioventricular septal defect, AVSD) between January 2012 and June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups. First, right sub-axillary vertical incision group (RSAVI group, N=335, 192 ASDs, 135 VSDs and 8 AVSDs; Second, right anterolateral thoracotomy group (RALT group, N=132, 77 ASDs, 51 VSDs and 4 AVSDs; Third, left anterolateral thoracotomy group (LALT group, N=5, all of them were sub-pulmonary VSDs).Results: Concomitant surgeries included 9 cases of right ventricular outflow tract obstruction relief, 9 mitral repairs and 37 tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (2 residual shunts and 1 mitral regurgitation). The age and body weight of RSAVI group were significantly lower than those of RALT and LALT groups. The mean cardiopulmonary bypass time was 67.3±11.3 min and cross clamp time was 38.1±8.9 min. There was no post-operative death, and complications included 1 chest exploration for bleeding, 1 redo operation due to patch dehiscence during the same admission, 1 transient neural dysfunction, 3 diaphragmatic paresis and 13 atelectasis. The median stay in ICU was 2 days, while the median post-operative hospitalization was 6 days. The echocardiography results before discharge indicated no significant residual lesions. There was no reoperation, no new onset of chest deformities and no sclerosis during the follow up. Conclusions: The commonly seen intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. Right sub-axillary vertical incision is suitable in infants and young children, while right anterior mini-thoracotomy is more commonly used in adolescents and adults. Left anterior mini-thoracotomy is an alternative incision to repair sub-pulmonary artery VSD.