MINIMALLY INVASIVE MITRAL VALVE REPLACEMENT (MIMVR) THROUGH RIGHT MINITHORACOTOMY: A SINGLE-CENTER EXPERIENCE FROM CENTRAL INDIA

Background: Minimally invasive mitral valve replacement surgery (MIMVR) is gaining popularity for its multifold advantages. Here we report our single-institution experience with MIMVR through the right minithoracotomy over two years. Materials and Methods: This study was a retrospective analytical study. Forty-two patients undergoing MIMVR between August 2019 and July 2021 were included. Recorded perioperative data were collected and evaluated retrospectively. Results: A total of 42 patients were included in the study, of which 29 were females (69%). The mean age was 43.2+/- 8.2 years. Overall 30-day mortality was 2.38% (n = 1). Mean operating time, cardiopulmonary bypass, and aortic cross-clamp times were 264.9 ± 48.7, 151.5 ± 39.8, and 89.8 ± 25.6 minutes, respectively. Tricuspid valve annuloplasty was performed in 8 patients (19%). One patient (2.38%) required conversion to median sternotomy, and three patients (7.1%) underwent re-explorations due to bleeding. The median postoperative hospital stay was 5 days. Conclusions: MIMVR through right minithoracotomy is feasible, safe, and reproducible with low mortality and morbidity. Mitral valve surgery through a small anterior thoracotomy is a good alternative to conventional thoracotomy. Keywords: minimally invasive, minithoracotomy, mitral valve replacement

Characteristics of postoperative pain after mini invasive and conventional mitral surgery in Hanoi Heart Hospital

Introduction: Mini invasive mitral valve surgery had some advantages over conventional surgery in recovery and cosmestic results. Postoperative pain was an interested factor for comparing these two methods, with reported results remained unclear. We realized this study for evaluate the characteristics of postoperative pain between mini invasive and conventional mitral surgery in Hanoi Heart Hospital. Methods: A cross sectional study on patient underwent mitral valve replacement with mini invasive and conventional sternotomy approach. Results: There were 66 patients in the study, divided into 2 group: 43 patient underwent conventional surgery and 23 patient underwent mini invasive surgery. Mean age was 50,7 ± 9,3, female was 78,8% and mean BMI was 20,9 ± 2,7. Erector spinae plane (ESP) block was performed on 16 patients (24,2%) of conventional surgery group. The VAS score at 3 days, 7 days , and 1 month after surgery was 7,7 ± 1,2; 5,2 ± 1,5; 0,9 ± 1,1 in sternotomy group and 6,6 ± 1,6; 3,8 ± 1,5; 1,7 ± 0,9 in mini invasive group, respectively. In patients with ESP block, mean dose of morphine administered in first two days was 0 and 2,3 ± 5,0 mg/kg comparing to the dose of 19,7 ± 5,5 và 17,7 ± 7,1 in sternotomy patients without ESP block. Conclusions: Postoperative pain reduction may not be an advantage of mini invasive mitral surrgery comparing to conventional surrgery, but the time for pain suffering in this group was shorter. ESP was an efficient method for early pain reduction after conventional surgery.

A Simple Approach for Minimally Invasive Combined Aortic and Mitral Valve Surgery

Background There is now extension of minimally invasive techniques to involve concomitantly aortic and mitral valves through a single small incision. We share our experience in such surgeries through upper partial sternotomy with approaching the mitral valve through the dome of the left atrium. Methods Two matched groups of cases receiving concomitant aortic and mitral valve surgeries are compared regarding the surgical outcomes: the minimally invasive group (group A) including 72 patients and the conventional group (group B) including 78 patients. Results The mean age was 52 ± 8 years in group A and 53 ± 7 years in group B. Males represented (42%) in group A and (49%) in group B. The mean mechanical ventilation time was significantly shorter in group A (4.3 ± 1.2 hours) than in group B (6.1 ± 0.8 hours) with a p-value of 0.001. In addition, the amount of chest tube drainage and the need for blood transfusion units were significantly less in group A (250 ± 160 cm3 and 1.3 ± 0.8 units, respectively) when compared with group B (320 ± 180 cm3 and 1.8 ± 0.9 units, respectively) with p-values of 0.013 and 0.005, respectively. Over a follow-up period of 3.2 ± 1.1 years, one mortality occurred in each group with no significant difference (p-value = 0.512). Conclusion Combined aortic and mitral valve surgery through upper partial sternotomy with approaching the mitral valve through the dome of the left atrium is safe and effective with the advantages of less postoperative blood loss, need for blood transfusion, and mechanical ventilation time compared with conventional aortic and mitral valve surgery.

Fibrin Sealant Patch for the Management of Intractable Bleeding From an LVAD Apex Cannula

Background: Intractable bleeding from the apical cannulation site of a left ventricular assist device (LVAD) is a dreaded complication. Case report: A 52-year-old male suffering from dilative cardiomyopathy (DCM) with fixed pulmonary hypertension underwent reoperative LVAD implantation after previous mitral valve surgery. The patient underwent three rethoracotomies for bleeding from the apex cannulation site without achieving hemostasis. Conventional techniques and application of fibrin sealants and polymeric sealing devices did not fix the problem. The bleeding stopped after application of the EVARREST® Fibrin Sealant Patch (FSP), and he needed no further transfusions. Conclusion: This patch might become a useful tool for intractable bleeding problems in LVAD surgery.

Pass On What You Have Learned: A Structured Mentor-Mentee Concept for the Implementation of a Minimally Invasive Mitral Valve Surgery Program

<b><i>Introduction:</i></b> Starting a minimally invasive cardiac surgery (MICS) for mitral valve repair (MVR) program is challenging as it requires a new learning curve, but compromising surgical results at the same time is not acceptable. Here, we describe our surgical educational experience of starting a new MICS program at a university heart center in Germany. <b><i>Methods:</i></b> A dedicated team for the new MICS program including 2 cardiac surgeons, 1 cardiac anesthetist, 1 perfusionist, and 1 scrub nurse was chosen. The use of long shafted instruments was trained in a low-cost self-assembled MICS simulator, and the EACTS endoscopic dry lab course was visited. Thereafter, 1 MICS center was visited for direct observation and peer-to-peer education for 6 weeks. The mentor observed the first 10 cases performed by the mentee. The surgical mitral valve expertise of 1 single cardiac surgeon was retrospectively analyzed between April 2016 and April 2021. <b><i>Results:</i></b> Before the implementation of the MICS-MVR program, 18 mitral valve operations have been performed through sternotomy between April 2016 and October 2018 including 12 replacements and 6 ring annuloplasties. After starting the MICS-MVR program, 73 mitral operations have been performed by the same surgeon of which 53 video-assisted through minithoracotomy (72.6%). 83.1% of the MICS procedures included complex repair (<i>n</i> = 38) and ring annuloplasty (<i>n</i> = 6). Open heart MV surgery was necessary in 20 patients due to concomitant procedures (<i>n</i> = 8), redo procedures (<i>n</i> = 2), severe endocarditis (<i>n</i> = 4), or contraindication for MICS such as PAD (<i>n</i> = 6). There have been no deaths, 1 stroke, and 1 cardiac vascular (RCX) complication. Two patients required conversion to sternotomy and one pericardiocentesis in the long term. <b><i>Conclusion:</i></b> Typically, excellent exposure and high repair rates of the MV has led us offer MICS approach to a majority of patients with isolated MV disease. Careful planning and a strict mentor-mentee concept facilitated a safe startup of an MICS program in a busy university heart center.

Metabolic alkalosis following mitral valvuloplasty in a dog with preoperative acute kidney injury

CASE DESCRIPTION An 11-year-old sexually intact male Shih Tzu diagnosed with acute kidney injury and left-sided congestive heart failure that had nonelective mitral valve surgery. CLINICAL FINDINGS Metabolic alkalosis developed postoperatively, and plasma bicarbonate concentration peaked 2 days after surgery (40.2 mmol/L; pH, 7.550). TREATMENT AND OUTCOME Acetazolamide administration increased the urinary excretion of bicarbonate and contributed to the improvement of the dog’s acid-base status and oxygenation capacity. Metabolic alkalosis persisted for 4 days after surgery, and no treatment was required after resolution. Plasma urea nitrogen and creatinine concentrations normalized 2 days after surgery. CLINICAL RELEVANCE Severe metabolic alkalosis can occur as a complication following mitral valve surgery. Acetazolamide may be suitable for the treatment of severe metabolic alkalosis.