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A 69-year-old woman underwent aortic root reimplantation and graft replacement of the ascending aorta 12 years ago. A pseudoaneurysm (2.5 cm × 3 cm) arising from the side branch of the ascending aortic prosthetic graft was incidentally detected on contrast-enhanced computed tomography. After endovascular balloon occlusion of the side branch through the left subclavian artery, the side branch was exposed via right mini-thoracotomy in the third intercostal space. After circumferential dissection, the side branch was ligated uneventfully. The patient was discharged home on postoperative day 7 without any complications. [ABSTRACT FROM AUTHOR]

We report a case with a retrosternal gastric tube after oesophagectomy, who required left atrial myxoma resection, pulmonary vein isolation and left atrial appendage closure. A right mini-thoracotomy approach was adopted to avoid neo-oesophagus injury, and nitric oxide inhalation was useful to facilitate one-lung ventilation while dissecting the pleural adhesion. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Re-expansion pulmonary oedema (RPO) sometimes occurs after minimally invasive cardiac surgery (MICS) with single-lung ventilation. However, it has not been widely recognized as a serious complication. The aim of this study is to evaluate the occurrence rate and risk factors of RPO. METHODS: A total of 381 consecutive patients who underwent MICS with right mini-thoracotomy from March 2005 to October 2013 were retrospectively reviewed. RESULTS: RPO was observed in 8 (2.1%) patients. In the preoperative data, greater percentages of preoperative use of steroid or immunosuppressant were found in patients with RPO (25% [2/8] vs 1% [4/373]; P = 0.0056). In the operative data, significantly longer operation, cardiopulmonary bypass (CPB) and aortic cross-clamping (ACC) times as well as greater percentages of second CPB run were found in patients with RPO (388 ± 80 vs 272 ± 61 min; P < 0.0002, 253 ± 79 vs 158 ± 50 min; P = 0.0009, 162 ± 65 vs 108 ± 38 min; P = 0.020 and 38% [3/8] vs 1.3% [5/373]; P < 0.0003). The overall 30-day mortality rate was 0.8% (3/381) and the 30-day mortality rate of patients with RPO was 12.5% (1/8). Significantly prolonged initial ventilation time, intensive care unit and postoperative hospital stay were observed in patients with RPO (P = 0.0022, <0.0001 and 0.0003, respectively). Multivariate logistic analysis detected preoperative use of steroid or immunosuppressant and prolonged ACC time (≥156 min) as independent risk factors for RPO after MICS (odds ratio [OR]: 87.6 [95% confidence interval, CI: 4.1–2463.8]; P = 0.006 and OR: 36.0 [95% CI: 4.8–731.4]; P < 0.001). CONCLUSIONS: RPO should be recognized as one of the most serious complications after MICS with right mini-thoracotomy. More accurate risk factors of prolonged lung malperfusion and steroid use on RPO after MICS should be investigated. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The aim of this study was to compare early outcomes and mid-term survival of high-risk patients undergoing minimally invasive aortic valve replacement through right anterior mini-thoracotomy (RT) with sutureless valves versus patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. METHODS: From October 2008 to March 2013, 269 patients with severe aortic stenosis underwent either RT with perceval S sutureless valves (n = 178 patients, 66.2%) or TAVI (n = 91, 33.8%: 44 transapical and 47 trans-femoral). Of these, 37 patients undergoing RT with the perceval S valve were matched to a TAVI group by the propensity score. RESULTS: Baseline characteristics were similar in both groups (mean age 79 ± 6 years) and the median logistic EuroSCORE was 14% (range 9-20%). In the matched group, the in-hospital mortality rate was 8.1% (n = 3) in the TAVI group and 0% in the RT group (P = 0.25). The incidence rate of stroke was 5.4% (n = 2) versus 0% in the TAVI and RT groups (P = 0.3). In the TAVI group, 37.8% (n = 14) had mild paravalvular leakage (PVL) and 27% (n = 10) had moderate PVL, whereas 2.7% (n = 1) had mild PVL in the RT group (P < 0.001). One- and 2-year survival rates were 91.6 vs 78.6% and 91.6 vs 66.2% in patients undergoing RT with the perceval S sutureless valve compared with those undergoing TAVI, respectively (P = 0.1). CONCLUSIONS: Minimally invasive aortic valve replacement with perceval S sutureless valves through an RT is associated with a trend of better early outcomes and mid-term survival compared with TAVI. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Advances in video-assistance lead to an increase in minimal access mitral valve surgery (MAMVS) with decreased incision size yet maintaining the same quality of surgery. Further reduction in surgical trauma and at the same time improved visual guidance can be achieved by a non-rib-spreading fully 3D endoscopic technique (NRS-3D). We compared patients who underwent MAMVS either through an NRS fully 3D endoscopic or rib-spreading (RS) access in a retrospective matched-pair analysis. METHODS: A matched pairs analysis was undertaken of retrospectively collected data of 284 consecutive patients having received an MAMVS between January 2011 and May 2015. Fifty patients with an RS procedure were compared with 50 patients with an NRS fully 3D endoscopic operation. For all patients, access was made through a 3-4 cm incision in the inframammary fold through the fourth intercostal space. In the NRS-3D group, only a soft-tissue protector, and no additional rib-spreader, was used. Operative visualization was provided by 3D endoscopy in the NRS-3D group. RESULTS: The NRS as well as the RS procedure was successful in all patients without technical repair limitations. Mortality was 0% in both groups. Significant differences were seen for operation times (39.0 min mean shorter operation time in the NRS-3D group; P < 0.001), and length of stay on intensive care unit (1.0 day mean shorter stay in the NRS-3D group; P = 0.002) and in the hospital (1.4 days mean shorter stay in the NRS-3D group; P = 0.003). Postoperative analgesics doses were significantly lower in the NRS-3D group [P = 0.007 (paracetamol); P = 0.123 (metamizole); P = 0.013 ( piritramide)]. Postoperative pain rated on a pain-scale from 0 to 10 was significantly lower in the NRS-3D group (mean difference of 1.8; P = 0.006). Patient satisfaction regarding cosmetic results was comparable in both the groups. Repair results, ejection fraction, perioperative morbidity and MACCE during follow-up showed no significant differences between both groups. Early postoperative and follow-up echocardiography showed sufficient repair in all patients of both groups with no case of >mild recurrent mitral regurgitation. CONCLUSIONS: An endoscopic procedure supported by 3D-visualization enables superior depth perception, facilitating an excellent quality of repair results. 3D-visualization is a helpful tool especially for complex reconstruction cases and exact placement of artificial neochordae. With this, an experienced mitral valve surgeon takes shorter operation times. Patients benefit from shorter hospitalization with reduced postoperative pain and early mobilization. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To prospectively assess the impact of intrapleural intercostal nerve block (IINB) associated with mini-thoracotomy on postoperative pain and surgical outcome after major lung resections. Methods: Between January 2004 and February 2005, we randomly assigned 120 consecutive patients undergoing mini-thoracotomy (10–13cm) for major lung resections, to receive or not IINB from the 4th to the 8th space at the moment of thoracotomy using 20ml (7.5mg/ml) ropivacain injection at the dose of 4ml for each space. Postoperative analgesia consisted of continuous intravenous infusion of tramadol (10mg/h) and ketoralac tromethamine (3mg/h) for 48h for all patients. Results: The two groups (60 patients each) were comparable for age, sex, pulmonary function, type and duration of the procedure. Mortality and morbidity were 0% and 10%, respectively, for the IINB group and 3.3% and 15%, respectively, for the non-IINB group (p >0.05, NS). Mean postoperative pain measured by the ‘Visual Analogue Scale’ were as follows: 2.3±1 at 1h, 2.2±0.8 at 12h, 1.8±0.7 at 24h, and 1.6±0.6 at 48h for the IINB group; and 3.6±1.4 at 1h, 3.4±2 at 12h, 2.9±1.2 at 24h, and 2.0±1 at 48h for the non-IINB group. Differences were significant at 1h, 12h, 24h, and 48h (p <0.05). Mean postoperative hospital stay was 5.7 days in the IINB group and 6.5 days in the non-IINB group (p <0.05). Conclusion: IINB associated with mini-thoracotomy reduces postoperative pain and contributes to improve postoperative outcome after major pulmonary resections. [Copyright &y& Elsevier]

We describe herein the first experience with a surgical technique for aortic valve replacement using a video-assisted minimally invasive approach via a left anterior mini-thoracotomy in patient with dextrocardia and situs inversus totalis. This procedure was performed safely with good clinical and cosmetic results. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Minimally invasive access has become the preferred choice in mitral and/or tricuspid valve surgery. Reported outcomes are at least similar to classic sternotomy although aortic cross-clamp times are usually longer. METHODS We analysed the largest registry of mitral and/or tricuspid valve surgery patients (mini-mitral international registry (MMIR)) for the relationship between aortic cross-clamp times, mortality and other outcomes. From 2015 to 2021, 7513 consecutive patients underwent mini-mitral and/or tricuspid valve surgery in 17 international Heart-Valve-Centres. Data were collected according to Mitral Valve Academic Research Consortium (MVARC) definitions and 6878 patients with 1 cross-clamp period were analysed. Uni- and multivariable regression analyses were used to assess outcomes in relation to aortic cross-clamp times. RESULTS Median age was 65 years (57% male). Median EuroSCORE II was 1.3% (Inpatient Quality Reporting (IQR): 0.80–2.63). Minimally invasive access was either by direct vision (28%), video-assisted (41%) or totally endoscopic/robotic (31%). Femoral cannulation was used in 93%. Three quarters were repairs with 17% additional tricuspid valve surgery and 19% Atrial Fibrillation (AF)-ablation. Cardiopulmonary bypass and cross-clamp times were 135 min (IQR: 107–173) and 85 min (IQR: 64–111), respectively. Postoperative events were death (1.6%), stroke (1.2%), bleeding requiring revision (6%), low cardiac output syndrome (3.5%) and acute kidney injury (6.2%, mainly stage I). Statistical analyses identified significant associations between cross-clamp time and mortality, low cardiac output syndrome and acute kidney injury (all P  < 0.001). Age, low ejection fraction and emergent surgery were risk factors, but variables of 'increased complexity' (redo, endocarditis, concomitant procedures) were not. CONCLUSIONS Aortic cross-clamp time is associated with mortality as well as postoperatively impaired cardiac and renal function. Thus, implementing measures to reduce cross-clamp time may improve outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES Barlow's disease is a specific sub-form of mitral valve (MV) disease, characterized by diffuse excessive tissue and multi segment prolapse. The anterolateral mini-thoracotomy represents the standard access for MV regurgitation in many centres. It still remains unclear which surgical technique provides the best results. Therefore, the aim of this study was to compare operative safety and mid-term outcomes after (i) isolated annuloplasty, (ii) use of additional artificial chordae or (iii) leaflet resection in patients suffering from Barlow's disease undergoing minimally invasive MV repair. METHODS A consecutive series of patients suffering from Barlow′s disease undergoing minimally invasive MV surgery between 2001 and 2020 were analysed (n  = 246). Patients were grouped and analysed according to the used surgical technique. The primary outcome was a modified Mitral Valve Academic Research Consortium combined end-point of mortality, reoperation due to repair failure or reoccurrence of severe mitral regurgitation within 5 years. The secondary outcome included operative success and safety up to 30 days. RESULTS No significant difference was found between the 3 surgical techniques with regard to operative safety (P  = 0.774). The primary outcome did not differ between groups (P  = 0.244). Operative success was achieved in 93.5% and was lowest in the isolated annuloplasty group (77.1%). Conversion to MV replacement was increased in patients undergoing isolated annuloplasty (P  < 0.001). CONCLUSIONS Isolated annuloplasty, use of additional artificial chordae and leaflet resection represent feasible techniques in Barlow patients undergoing minimally invasive MV surgery with comparable 5-year results. In view of the increased conversion rate in the annuloplasty group, the pathology should not be oversimplified. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Thoracoscopic ablation for atrial fibrillation (AF) and minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal mammary artery (LIMA) harvesting may represent a safe and effective alternative to more invasive surgical approaches via sternotomy. The aim of our study was to describe the feasibility, safety and efficacy of a unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB surgery. METHODS Retrospective analysis of a prospectively gathered cohort was performed of all consecutive patients with AF and at least a critical left anterior descending artery (LAD) stenosis that underwent unilateral left-sided thoracoscopic AF ablation and concomitant off-pump MIDCAB surgery in the Maastricht University Medical Centre between 2017 and 2021. RESULTS Twenty-three patients were included [age 69 years (standard deviation = 8), paroxysmal AF 61%, left atrial volume index 42 ml/m2 (standard deviation = 11)]. Unilateral left-sided thoracoscopic isolation of the left (n  = 23) and right (n  = 22) pulmonary veins and box (n  = 21) by radiofrequency ablation was succeeded by epicardial validation of exit- and entrance block (n  = 22). All patients received robot-assisted LIMA harvesting and off-pump LIMA-LAD anastomosis through a left mini-thoracotomy. The perioperative complications consisted of one bleeding of the thoracotomy wound and one aborted myocardial infarction not requiring intervention. The mean duration of hospital stay was 6 days (standard deviation = 2). After discharge, cardiac hospital readmission occurred in 4 patients (AF n  = 1; pleural- and pericardial effusion n  = 2, myocardial infarction requiring the percutaneous intervention of the LIMA-LAD n  = 1) within 1 year. After 12 months, 17/21 (81%) patients were in sinus rhythm when allowing anti-arrhythmic drugs. Finally, the left atrial ejection fraction improved postoperatively [26% (standard deviation = 11) to 38% (standard deviation = 7), P  =   0.01]. CONCLUSIONS In this initial feasibility and early safety study, unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB for LIMA-LAD grafting is a feasible, safe and efficacious for patients with AF and a critical LAD stenosis. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Concerns exist about higher rates of pacemaker implantation using the extended superior transseptal approach for mitral valve surgery. This study aims to compare the extended superior transseptal and the left atrial approach regarding the need for pacemaker implantation after mitral valve surgery. METHODS We performed a retrospective analysis of the data of patients undergoing mitral valve surgery through either a sternotomy and transseptal approach or a mini-thoracotomy and left atrial approach in a single centre in the period January 2010 to May 2021. The primary outcome was the evaluation of the postoperative pacemaker implantation rate. RESULTS Overall, 677 patients were included, 333 with transseptal and 344 with left atrial approach, and 58 (8.6%) patients underwent pacemaker implantation postoperatively. There was no significant difference in the rate of pacemaker implantation between the 2 groups [overall: 34 (10.2%) vs 24 (7%), P  = 0.133; for sinus node dysfunction: 12 (3.6%) vs 9 (2.6%), P  = 0.459; for high-degree atrioventricular block: 22 (6.6%) vs 15 (4.4%), P  = 0.199; transseptal vs left atrial approach, respectively]. A subgroup analysis of the relative effect of transseptal versus left atrial approach on the rate of postoperative pacemaker implantation revealed mitral replacement as a statistically significant confounder (P  = 0.019). The exclusion of patients undergoing concomitant cardiac procedures did not lead to a statistically significant difference in the pacemaker implantation rate between the 2 approaches. CONCLUSIONS The analysis of the data of these patients shows no significant difference in the rate of permanent pacemaker implantation between the extended superior transseptal and the left atrial approach for mitral valve surgery. [ABSTRACT FROM AUTHOR]

In minimally invasive coronary artery bypass (MICAB), a video-assisted needle-guided technique was used to make a mini-thoracotomy or an access-port just above the target site in the left anterior descending coronary artery (LAD). After thoracoscopic preparation of the left internal thoracic artery (LITA) and pericardiotomy, a 7-cm, 23-gauge needle was used to examine the skin-point where the needle vertically penetrated the chest wall and thoracoscopically indicated the target site in the LAD. This point was used as the mid-point of the skin incision for a 6-cm thoracotomy (six cases) or a 33-mm access-port (four cases). Consequently, there was no conversion of approach except in the patient with pulmonary dysfunction, and each LITA–LAD anastomosis was completed directly through the mini-entry. There was no mortality and no procedure-related morbidity. Patency of each graft was confirmed within a week after surgery. After a mean follow-up period of 12.5±7.8 months, all of the patients except one, who died of stroke 1 year after surgery, are alive with no ischemic events. Although our experience is limited, the present video-assisted needle-guided technique can be a simple method to facilitate appropriate positioning of a mini-entry in MICAB to the LAD with a thoracoscopically prepared LITA graft. [Copyright &y& Elsevier]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Left coronary vessels are the usual targets in totally endoscopic coronary artery bypass (TECAB). Grafting of the right coronary artery (RCA) has been limited using this approach because of anatomic and technical difficulties. We report a first series of robotic beating-heart TECAB to the RCA via a right-chest approach. METHODS From July 2013 to April 2019, patients who underwent robotic beating-heart TECAB with the right internal mammary artery to the RCA were reviewed. Port placement in the right chest mirrored standard left-sided ports. Indications for right internal mammary artery to RCA bypass were RCA disease not amenable to percutaneous intervention and anomalous origin of the RCA. RESULTS Right internal mammary artery–RCA bypass was performed in 16 patients (mean age 60.6 ± 13.5, 75% male). All cases were completed without conversion to sternotomy or mini-thoracotomy. Cardiopulmonary bypass was required in 1 patient to expose the posterior descending artery. Mean procedure time was 223 ± 49 min, with half of the patients extubated in the operating room (50%). Mean intraoperative transit-time graft flow was 87.0 ± 19.3 ml/min, and a pulsatility index of 1.2 ± 0.2. Mean length of stay was 2.3 ± 1.2 days. No mortality was observed at mean follow-up time of 20.6 months. One patient required repeat RCA revascularization for progression of native disease 43.7 months after the surgery. CONCLUSIONS Robotic beating-heart TECAB for isolated RCA disease is a feasible operation in selected patients. This technique is possible even for the posterior descending artery. [ABSTRACT FROM AUTHOR]

OBJECTIVES The management of postoperative pain in thoracic surgery is an open issue. The aim of this study was to compare postoperative pain after a videothoracoscopic lobectomy versus a mini-thoracotomy approach. METHODS Between April 2011 and January 2013 we enrolled in a prospective, non-randomized study 145 patients undergoing pulmonary lobectomy with lymphadenectomy for Stage I lung cancer. In 75 cases (Group A), surgery was performed through a videothoracoscopic approach. In 70 cases (Group B), surgery was undertaken through a conservative mini-thoracotomy. Pain was assessed by visual analogue scale and lung function by spirometry and six-minute walking test (6MWT) before surgery, at 48 h and 1 month after surgery. RESULTS Patients were stratified by age, sex, lung function, type and duration of surgery. Length of hospital stay (median, days) was 4 for Group A and 6 for Group B (P = 0.088). The differences between mean postoperative pain values were significant at 1, 12, 24 and 48 h (6.24 vs 8.74, 5.16 vs 7.66, 4.19 vs 6.89 and 2.23 vs 5.33; P = 0.000). In Group A, mean preoperative forced expiratory volume in 1 second values were 2.65 ± 0.61, and 1.83 ± 0.65 and 2.09 ± 0.65, respectively, at 48 h and 1 month (P = 0.028); in Group B, they were 2.71 ± 0.71 preoperatively and 1.33 ± 0.52 and 1.82 ± 0.63, respectively, at 48 h and 1 month. In Group A, mean preoperative 6MWT values (m) were 426.85 ± 51.18, and 371.23 ± 55.36 and 392.07 ± 56.12, respectively, at 48 h and 1 month; in Group B, they were 421.76 ± 56.65 preoperatively and 312.03 ± 48.54 and 331.83 ± 47.99, respectively, at 48 h and 1 month (P = 0.000). CONCLUSIONS The videothoracoscopic approach in the treatment of Stage I lung cancer reduces postoperative pain, which seems to allow a rapid functional recovery of patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We recently developed a novel minimally invasive surgical approach that combines extracorporeal membrane oxygenation and CentriMag ventricular assist device (Ec-VAD) for the treatment of cardiogenic shock as a short-term circulatory support. We compared the outcomes of this new approach to conventional CentriMag biventricular assist device (BiVAD) support through a median sternotomy. METHODS: Between July 2015 and August 2016, 22 patients were implanted with CentriMag Ec-VAD and 90 patients were implanted with conventional CentriMag BiVAD. The Ec-VAD circuit was configured with left ventricular apical cannulation via a mini-thoracotomy and femoral venous cannulation as inflows and right axillary artery cannulation as an outflow. RESULTS: Patients with Ec-VAD were older (58 ± 9.9 vs 53 ± 13 years, P = 0.06), had more preoperative percutaneous mechanical circulatory support use (82% vs 44%, P < 0.01) and less cardiopulmonary bypass use intraoperatively (0% vs 66%, P < 0.01). Patients who received Ec-VAD required less transfusions. The Ec-VAD group had a significantly lower incidence of major bleeding events during support (32% vs 72%, P < 0.01). Average systemic flow was similar (Ec-VAD: 5.5 ± 0.94 vs BiVAD: 5.7 ± 1.1 l/min, P = 0.4). Seventeen patients (77%) with Ec- VAD survived to the next destination compared with 66 patients (73%) with BiVAD (P = 0.45). Thirty-day survival was similar between groups (Ec-VAD 86% vs BiVAD 76%, P = 0.39), and overall 1-year survival was 61% in Ec-VAD and 55% in BiVAD (P = 0.7). CONCLUSIONS: Ec-VAD is a unique approach for the treatment of patients in cardiogenic shock. It eliminates the need for cardiopulmonary bypass and reduces blood product utilization and bleeding events. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This prospective study is an evaluation of the mini-open vacuum-assisted closure with instillation (Mini-VAC-Instill) therapy for the treatment of complicated pleural empyema. METHODS: We investigated septic patients in poor general physical condition (Karnofsky index =50%) with multimorbidity and/or immunosuppression who were treated by minimally invasive intrathoracic VAC-Instill therapy without the insertion of an open-window thoracostomy (OWT) between December 2012 and November 2014. All patients underwent mini-thoracotomy with position of a tissue retractor, surgical debridement and local decortication. Surgery was followed by intrathoracic vacuum therapy including periodic instillation using antiseptics. The VAC dressings were changed under general anaesthesia and the chest wall was closed during the same hospital stay. All patients received systemic antibiotic therapy. RESULTS: Fifteen patients (13 males, median age: 71 years) underwent intrathoracic Mini-VAC-Instill dressings for the management of pleural empyema without bronchopleural fistula. The median length of vacuum therapy was 9 days (5-25 days) and the median number of VAC changes per patient was 1 (1-5). In-hospital mortality was 6.7% (n = 1) and was not related to Mini-VAC-Instill therapy or intrathoracic infection. Control of intrathoracic infection and closure of the chest cavity was achieved in 85.7% of surviving patients (12 of 14). After the follow-up at an average of 13.2 months (range, 3-25 months), we observed recurrence once, 21 days after discharge. Two patients died in the late postoperative period (Day 43 and Day 100 after discharge) of fulminant urosepsis and carcinoma-related multiorgan failure, respectively. Analysis of the follow-up interviews in the outpatient clinic showed a good quality of life and a subjectively good long-term aesthetic result. CONCLUSIONS: Mini-VAC-Instill therapy is an upgrade of Mini-VAC, which guarantees the advantage of an open treatment, including flushing but without OWT. This procedure is minimally invasive, highly compatible especially with patients in poor general condition and may be an alternative to the OWT in selected patients. Consequently, a very short course of therapy results in good patient acceptance. [ABSTRACT FROM AUTHOR]

OBJECTIVES The purpose of this study was to evaluate the efficiency of our newly designed tactile mechanoreceptor in detection of pulmonary lesions during thoracoscopy. METHODS Twenty-seven patients with peripheral undetermined subpleural solitary pulmonary lesions detected on computed tomography were included in a prospective non-randomized trial. All nodules from 7 to 18 mm in diameter were located deep in the lung parenchyma (≥10 mm from the lung surface). All patients underwent thoracoscopic exploration with diagnostic intent. Instrumental palpation with lung forceps was performed first, followed by thorough inspection of lung tissue with the tactile mechanoreceptor. This device is a metal tube 10 mm in diameter, which can be inserted into the pleural cavity via a standard 10-mm port. There is an elastic membrane on its working end, which deforms greatly if the palpated tissue has greater density. Intraoperatively, the surgeon pushed the targeted region of pulmonary tissue with the mechanoreceptor and carried out the measurement. The density of tissue characteristics was displayed with special software using colour change in real time. After detection of a pulmonary nodule, it was resected with endostaplers. RESULTS Instrumental palpation was successful in detection of pulmonary lesions in 10 (37%) patients and was confirmed with the tactile mechanoreceptor. In 12 (44%) patients, instrumental palpation failed to locate an intrapulmonary nodule, while the tactile mechanoreceptor facilitated finding the lesion and performing thoracoscopic lung resection in all these patients. Intraoperative histological examination confirmed benign disease in 8, metastatic lesion in 12 and primary lung cancer in 7 patients requiring thoracoscopic lobectomy. In 5 (19%) patients, neither forceps nor the tactile mechanoreceptor was able to detect any pulmonary lesion, necessitating mini-thoracotomy for finger palpation. The overall efficacy of the tactile mechanoreceptor in detection of pulmonary lesions was 81%, and of impalpable nodes 71%. CONCLUSIONS The tactile mechanoreceptor is an effective tool for detection of impalpable pulmonary lesions during thoracoscopy. [ABSTRACT FROM AUTHOR]

OBJECTIVES The maintenance of a good surgical view is mandatory in video-assisted thoracoscopic surgery (VATS). For routine segmentectomy, it is necessary to re-inflate the lung in order to identify the intersegmental line. However, such re-inflation can occasionally obstruct the surgical view. Infrared thoracoscopy (IRT) with indocyanine green (ICG) can reveal the intersegmental line based on blood flow differences, without the need for lung re-inflation. The purpose of this study was to confirm the usefulness of IRT with ICG for VATS. METHODS Between October 2008 and September 2011, 44 consecutive patients underwent segmentectomy at our institution. In 13 patients, VATS segmentectomy using IRT with ICG was employed. Informed consent was obtained from all patients. Computed tomography was performed to identify the dominant pulmonary artery supplying the target segment. The operations were performed using two ports and one mini-thoracotomy (3–6 cm). The dominant arteries were interrupted, and the intersegmental line was identified using IRT with ICG. RESULTS Identification of the intersegmental line was possible in 11 (84.6%) of the 13 patients. The average age was 70 years, and 6 of the patients were male. The mean operation time was 191 min, and the mean bleeding volume was 64 ml. The operation time and bleeding volume were similar to the values in the other 31 patients who underwent thoracotomy (167 min/115 ml, P = 0.212/0.361, respectively). No complications attributable to IRT with ICG were observed. CONCLUSIONS VATS segmentectomy using IRT with ICG allows the maintenance of a clear surgical view and identification of the intersegmental line in a high proportion of cases. Therefore, we consider this method to be useful for minimally invasive thoracic surgery. [ABSTRACT FROM PUBLISHER]

We present a complicated case of massive pulmonary embolism occurring 11 weeks after a craniotomy in a patient with multiple high-risk comorbidities. The patient underwent successful pulmonary artery surgical embolectomy via left mini-thoracotomy incision on peripheral venoarterial extracorporeal membrane oxygenation support. For this patient, avoiding a sternotomy allowed for greatly decreased postoperative morbidity and the use of venoarterial extracorporeal membrane oxygenation allowed for the avoidance of intraoperative anticoagulation. This case demonstrates the feasibility of off-pump surgical pulmonary embolectomy via left mini-thoracotomy as a treatment strategy for appropriate patients to improve patient-centred care. [ABSTRACT FROM AUTHOR]

Abstract: Background: Re-do mitral valve procedures performed through median sternotomy carry substantial mortality and morbidity. To avoid complications of sternal re-entry and to provide adequate mitral valve exposure, antero-lateral thoracotomy has been suggested by some authors. Methods: From October 1997 to January 2007, 677 mitral valve operations have been performed in our centre using port-access video-assisted right mini-thoracotomy. Among these, 241 (35.6%) were performed on patients who had undergone one or more previous cardiac surgery procedures. Results: Mean cardio-pulmonary bypass time and endo-clamp time were 117±46min and 71±31min, respectively. Arterial cannulation was performed either on the ascending aorta, with the endo-direct cannula (112 patients, 46.5%), or peripherally with a femoral artery approach (129 patients, 53.5%). Conversion to median sternotomy was necessary in only two patients (0.8%) due to aortic dissection (one case) and left ventricle free wall rupture (one case). Median intensive care unit stay was 24h, median mechanical ventilation time was 12h; median hospital stay was 8 days. Bleeding requiring surgical revision occurred in 12 patients (4.9%). Hospital mortality was 4.9% (12/241 patients). Conclusions: Port-access video-assisted right mini-thoracotomy allows good results in a difficult subset of patients; it allows minimal adhesion dissection, short ICU and hospital stay. In our practice, this technique has become the treatment of choice for mitral valve re-do surgery. [Copyright &y& Elsevier]

Open in new tab Download slide OBJECTIVES The aim of this study was to examine the incidence and predictors of stroke after minimally invasive mitral valve surgery (mini-MVS) and to assess the role of preoperative CT scan on surgical management and neurological outcomes in the large cohort of Mini-Mitral International Registry. METHODS Clinical, operative and in-hospital outcomes in patients undergoing mini-MVS between 2015 and 2021 were collected. Univariable and multivariable analyses were used to identify predictors of stroke. Finally, the impact of preoperative CT scan on surgical management and neurological outcomes was assessed. RESULTS Data from 7343 patients were collected. The incidence of stroke was 1.3% (n  = 95/7343). Stroke was associated with higher in-hospital mortality (11.6% vs 1.5%, P  < 0.001) and longer intubation time, ICU and hospital stay (median 26 vs 7 h, 120 vs 24 h and 14 vs 8 days, respectively). On multivariable analysis, age (odds ratio 1.039, 95% confidence interval 1.019–1.060, P  < 0.001) and mitral valve replacement (odds ratio 2.167, 95% confidence interval 1.401–3.354, P  < 0.001) emerged as independent predictors of stroke. Preoperative CT scan was made in 31.1% of cases. These patients had a higher risk profile and EuroSCORE II (median 1.58 vs 1.1, P  < 0.001). CT scan influenced the choice of cannulation site, being ascending aorta (18.5% vs 0.5%, P  < 0.001) more frequent in the CT group and femoral artery more frequent in the no CT group (97.8% vs 79.7%, P  < 0.001). No difference was found in the incidence of postoperative stroke (CT group 1.5, no CT group 1.4%, P  = 0.7). CONCLUSIONS Mini-MVS is associated with a low incidence of stroke, but when it occurs it has an ominous impact on mortality. Preoperative CT scan affected surgical cannulation strategy but did not led to improved neurological outcomes. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Our goal was to describe the technique for and evaluate the results of the isolated coronary artery bypass grafting or combined grafting procedures with mitral valve repair/replacement and/or left ventricle aneurysm repair performed through a single left anterior minithoracotomy. METHODS Perioperative data of all patients who required isolated or combined coronary grafting from July 2017 to December 2021 were observed. The focus was on 560 patients who underwent isolated or combined multivessel coronary bypass using the "Total Coronary Revascularization via left Anterior Thoracotomy" technique. The main perioperative outcomes were analysed. RESULTS A left anterior minithoracotomy was used in 521 (97.7%) out of 533 patients who required isolated multivessel surgical coronary revascularization and in 39 (32.5%) out of 120 patients who required combined procedures. In 39 patients, multivessel grafting was combined with 25 mitral valve and 22 left ventricular procedures. Mitral valve repair was performed through the aneurysm (n = 8) or through the interatrial septum (n = 17). Perioperative outcomes in isolated and combined groups were next: aortic cross-clamp time—71.9 (SD: 19.9) and 120 (SD: 25.8) min; cardiopulmonary bypass time—145.7 (SD: 33.5) and 216 (SD: 45.8) min; total operating time—269 (SD: 51.8) and 324 (SD: 52.1) min; intensive care unit stay—2 (2–2) and 2 (2–2) days; total hospital stay—6 (5–7) and 6 (5–7) days; and total 30-day mortality was 0.54 and 0%, respectively. CONCLUSIONS A left anterior minithoracotomy can be effectively used as a first-choice approach to perform isolated multivessel coronary grafting and can be combined with mitral valve and/or left ventricular repair. Experience with isolated coronary grafting through an anterior minithoracotomy is required to achieve the satisfactory results in combined procedures. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Surgical repair remains the best treatment for severe primary mitral regurgitation (MR). Minimally invasive mitral valve surgery is being increasingly performed, but there is a lack of solid evidence comparing thoracoscopic with conventional surgery. Our objective was to compare outcomes of both approaches for repair of leaflet prolapse. METHODS All consecutive patients undergoing surgery for severe MR due to mitral prolapse from 2012 to 2020 were evaluated according to the approach used. Freedom from mortality, reoperation and recurrent severe MR were evaluated by Kaplan–Meier method. Differences in baseline characteristics were adjusted with propensity score-matched analysis (1:1, nearest neighbour). RESULTS Three hundred patients met inclusion criteria and were divided into thoracoscopic (N  = 188) and conventional (sternotomy; N  = 112) groups. Unmatched patients in the thoracoscopic group were younger and had lower body mass index, New York Heart Association class and EuroSCORE II preoperatively. After matching, thoracoscopic group presented significantly shorter mechanical ventilation (9 vs 15 h), shorter intensive care unit stay (41 vs 65 h) and higher postoperative haemoglobin levels (11 vs 10.2 mg/dl) despite longer bypass and cross-clamp times (+30 and +17 min). There were no differences in mortality or MR grade at discharge between groups nor differences in survival, repair failures and reinterventions during follow-up. CONCLUSIONS Minimally invasive mitral repair can be performed in the majority of patients with mitral prolapse, without compromising outcomes, repair rate or durability, while providing shorter mechanical ventilation and intensive care unit stay and less blood loss. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection, and valve exposure in minimally invasive mitral valve surgery. The aim of this study is to compare the early outcomes of patients operated using a simplified minimally invasive approach through a right transaxillary (TAxA) access with those achieved with conventional full sternotomy (FS) operations. METHODS Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at 2 academic centres were reviewed. Among them, 454 patients were operated through minimally invasive mitral valve surgery TAxA access and 667 patients through FS; associated aortic and coronary arteries surgery (CABG) procedures, infective endocarditis, redo and urgent operations were excluded. A propensity-matched analysis was performed using 17 preoperative variables. RESULTS Two well-balanced cohorts including a total of 804 patients were analysed. The rate of mitral valve repair was similar in both groups. Operative times were shorter in the FS group; nevertheless, in patients operated with a minimally invasive approach, there was a trend towards decreasing cross-clamp time over the study period (P  = 0.07). In the TAxA group, 30-day mortality was 0.25%, and postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (P  < 0.001) and intensive care unit stay (P  < 0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home versus 5% in the FS group (P  < 0.001). CONCLUSIONS When compared with FS access, TAxA approach provides at least similar excellent early outcomes in terms of perioperative morbidity and mortality and allows shorter mechanical ventilation time, intensive care unit and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation. [ABSTRACT FROM AUTHOR]

We present a case of a 58-year-old man for surgical myectomy due to recurrent left ventricular outflow tract (LVOT) obstruction, who had prior transaortic septal myectomy and embolization of the septal branch. On admission, transthoracic echocardiography showed a typical hypertrophic obstructive cardiomyopathy (HOCM) with asymmetric septal hypertrophy, significant LVOT obstruction and severe mitral regurgitation due to the systolic anterior movement of the anterior mitral valve leaflet. We performed a novel procedure of the transapical beating-heart septal myectomy, following which the LVOT obstruction was resolved. And a decreased grade of systolic anterior movement and a reduction in the severity of mitral regurgitation were observed. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The objective of this single-centre, open, randomized control trial was to compare the patients' satisfaction with local anaesthesia (LA) or general anaesthesia (GA) for video-assisted thoracoscopy. METHODS Patients with indication for video-assisted thoracoscopy pleural management, mediastinal biopsies or lung wedge resections were randomized for LA or GA. LA was administered along with no or mild sedation and no airway devices maintaining spontaneous breathing, and GA was administered along with double-lumen tube and one-lung ventilation. The primary end point was anaesthesia-related satisfaction according to psychometrically validated questionnaires. Patients not willing to be randomized could attend based on their desired anaesthesia, forming the preference arm. RESULTS Fifty patients were allocated to LA and 57 patients to GA. Age, smoking habits and lung function were similarly distributed in both groups. There was no significant difference between the 2 groups with regard to patient satisfaction with anaesthesiology care (median 2.75 vs 2.75, P  = 0.74), general perioperative care (2.50 vs 2.50, P  = 0.57), recovery after surgery (2.00 vs 2.00, P  = 0.16, 3-point Likert scales). Surgeons and anaesthesiologists alike were less satisfied with feasibility (P  < 0.01 each) with patients in the LA group. Operation time, postoperative pain scales, delirium and complication rate were similar in both groups. LA patients had a significantly shorter stay in hospital (mean 3.9 vs 6.0 days, P  < 0.01). Of 18 patients in the preference arm, 17 chose LA, resulting in similar satisfaction. CONCLUSIONS Patients were equally satisfied with both types of anaesthesia, regardless of whether the type of anaesthesia was randomized or deliberately chosen. LA is as safe as GA but correlated with shorter length of stay. Almost all patients of the preference arm chose LA. Considering the benefits of LA, it should be offered to patients as an equivalent alternative to GA whenever medically appropriate and feasible. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Repair of the isolated degenerative anterior mitral leaflet has been considered more challenging and associated with compromised durability compared with isolated posterior leaflet in major series. Implantation of neochordae or Alfieri edge-to-edge is the most employed repair technique for isolated anterior repair currently, but little data exist comparing their relative durability. We sought to investigate this issue with this meta-analysis. METHODS A literature search was performed (Ovid MEDLINE, Ovid Embase and The Cochrane Library). The primary outcome was the incidence rate (IR) of reoperation, the secondary outcomes were recurrent moderately severe/severe mitral regurgitation (MR), in-hospital/30-day reoperation and mortality and follow-up mortality. A random-effect model was used. Leave-one-out, subgroup analysis (Alfieri versus neochordae) and meta-regression were done. RESULTS Seventeen studies (including 1358 patients) were included. At a weighted mean follow-up of 5.56 ± 3.31 years, the IR for reoperation was 14.45 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (9.40 vs 18.61, P  = 0.04) on subgroup analysis. The IR of follow-up moderately severe/severe MR was 19.89 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (10.68 and 28.63, P  = 0.01). In a sensitivity analysis comparing homogenous studies, a significant difference in the recurrence of regurgitation in favour of the Alfieri approach remained. There were no differences in operative outcomes or survival. There were significant associations between increased incidence of late reoperation and New York Heart Association class III/IV and associated coronary artery bypass graft procedure for whole cohort. CONCLUSIONS Alfieri repair may be associated with a lower incidence of recurrent MR compared with neochordae-based repair in the setting of isolated degenerative anterior mitral pathology. This is the first such meta-analysis and further inquiry into this area is needed. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Diffuse myxomatous mitral valve degeneration (DMD) represents a challenge in the reparative mitral valve surgery. A subgroup of patients with symmetrical DMD can be effectively treated with a simple band-annuloplasty with good early and mid-term results. Here, we evaluate the long-term outcomes in terms of freedom from reoperation, recurrence of moderate or severe mitral regurgitation (MR) and overall survival. METHODS Between April 2006 and December 2020, patients with DMD causing severe MR and the echocardiographic features of symmetrical bileaflet prolapse, central regurgitant jet(s), annular dilation and no chordal ruptures were treated using a simple annuloplasty with a semi-rigid band. These patients were prospectively collected and retrospectively analysed. RESULTS Seventy-five patients were enrolled. The mean clinical follow-up time was 104 [standard deviation (SD): 43] months, and echocardiographic follow-up time was 95 (SD: 43) months. The mean age was 54 (SD: 15) years, and 56% were females. Long-term overall survival was 98.2% [standard error (SE): 1.8], 93.7% (SE: 4.7) and 93.7% (SE: 4.7) at 4, 8 and 12 years, respectively. The freedom from reoperation was 100% at 4 and 8 years and 94.1% (SE: 5.7) at 12 years. The freedom from recurrent moderate or severe MR was 98.3% (SE: 1.7), 98.3% (SE: 1.7) and 92.8% (SE: 5.5) at 4, 8 and 12 years, respectively. CONCLUSIONS Mitral repair with the simple band-annuloplasty for the treatment of MR due to symmetrical DMD seems to be stable and effective in the long term. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Aortic valve replacement (AVR) for severe symptomatic aortic stenosis is one of the most common cardiac surgical procedures with excellent long-term outcomes. Multiple previous studies have compared short-term outcomes of AVR with mini-sternotomy versus AVR with conventional sternotomy. We have previously reported the results of the randomized MAVRIC trial, which aimed to evaluate early postoperative morbidity among patients undergoing mini-sternotomy and conventional sternotomy AVR. We now report the long-term all-cause mortality, reoperation, MACE outcomes and echocardiographic data from this trial. METHODS The prospective, randomized, single-centre, single-blind MAVRIC (manubrium-limited mini-sternotomy versus conventional sternotomy for aortic valve replacement) trial compared manubrium-limited mini-sternotomy and conventional median sternotomy for the treatment of patients with severe aortic stenosis. The previously reported primary outcome was the proportion of patients receiving red cell transfusion postoperatively and within 7 days of the index procedure. Currently reported exploratory analyses of a combined long-term all-cause mortality and reoperation were compared between groups via the log-rank test. Sensitivity analyses reviewed individual components of the combined end point. The primary analysis and long-term exploratory analyses were based on an intention-to-treat principle. RESULTS Between March 2014 and June 2016, 270 patients were enrolled and randomized in a 1:1 fashion to undergo mini-sternotomy AVR (n  = 135) or conventional median sternotomy AVR (n  = 135). At the median follow-up of 6.1 years, the composite outcome of all-cause mortality and reoperation occurred in 18.5% (25/135) of patients in the conventional sternotomy group and in 17% (23/135) of patients in the mini-sternotomy group. The incidence of chronic kidney disease, cerebrovascular accident and myocardial infarction was not significantly different between 2 groups. Follow-up echocardiographic data suggested no difference in peak and mean gradients or incidence of aortic regurgitation between 2 approaches. CONCLUSIONS This exploratory long-term analysis demonstrated that, in patients with severe aortic stenosis undergoing isolated AVR, there was no significant difference between manubrium-limited mini-sternotomy and conventional sternotomy with respect to all-cause mortality, rate of reoperation, MACE events and echocardiographic data at the median of 6.1-year follow-up. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES This study aimed to compare the real-world outcomes of segmentectomy and lobectomy for lung cancer after adjusting for background factors and the extent of lymphadenectomy. METHODS This retrospective cohort study used a nationwide database in Japan. The data of patients with clinical stage 0/IA lung cancer who underwent segmentectomy or lobectomy between 2017 and 2019 were retrieved. Short-term postoperative outcomes were compared between the segmentectomy and lobectomy groups using propensity score-matched analysis. RESULTS In the total cohort of 59 663 patients, 11 975 and 47 688 patients were in the segmentectomy and lobectomy groups, respectively. After propensity score matching, 8426 matched patients from each group were retrieved. All confounders including age, sex, comorbidities, smoking history, respiratory function, tumour size, clinical stage, affected lobe and extent of lymphadenectomy were appropriately adjusted. The overall complication rate and the cardiopulmonary complication rate were lower in the segmentectomy group than in the lobectomy group (8.5% vs 11.2%, P  < 0.001 and 7.5% vs 10.3%, P  < 0.001, respectively). The incidence of prolonged air leak was also lower after segmentectomy than after lobectomy (3.6% vs 5.3%). Surgical mortality, operative time and blood loss volume were comparable between the 2 groups. CONCLUSIONS The postoperative complication rate was lower with segmentectomy than with lobectomy for early-stage lung cancer. [ABSTRACT FROM AUTHOR]

Acute type A aortic syndromes are catastrophic events whose management relies primarily on conventional surgery. For several years, various endovascular attempts have been described; however, long-term data are inexistent. We describe a case of stenting of the ascending aorta for a type A intramural haematoma with survival and freedom from reintervention at >8 years postoperatively. [ABSTRACT FROM AUTHOR]