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Background: Carney complex is a rare syndrome characterized by skin pigmentation, endocrine disorders, and myxomas. It is particularly notorious for its tendency to exhibit aggressive cardiac myxomas. Herein, we present a case of a juvenile female patient diagnosed with Carney complex who underwent a right lateral mini-thoracotomy. Case presentation: A 13-year-old girl presented with sudden-onset left hemiplegia and dysarthria. Magnetic resonance imaging revealed multiple areas of restricted diffusion. Echocardiography identified a tumor in the left atrium, suspected to be related to Carney complex based on her medical history and physical examination findings. Surgery was performed via right lateral mini-thoracotomy, which minimized the risk of embolism and ensured a cosmetically favorable outcome. The left atrial wall defect was repaired with autologous pericardium. At 3 years postoperatively, follow-up echocardiography indicated no tumor recurrence and normal cardiac function. Conclusions: Ongoing follow-ups are essential due to the aggressive nature of the Carney complex and its high recurrence rates. Right lateral mini-thoracotomy offers the advantage of avoiding re-sternotomy and minimizing adhesion dissection, making it the optimal choice for this case. [ABSTRACT FROM AUTHOR]

Background: The incidence of minimally invasive heart surgery via mini-thoracotomy (MT; right anterior thoracotomy) is on the rise, accompanied by an increase in post-MT intercostal nerve neuralgia and the risk of lung herniation through the incision site. While various methods have been proposed to address these issues, none have been commonly effective. In this case report, we attempted to simultaneously address these problems by performing intercostal cryoablation (IC) and mesh repair. Case presentation: A 43-year-old male was referred to our hospital for chronic post-thoracotomy neuralgia following heart surgery via MT, involving patch closure of an atrial septal defect and tricuspid annuloplasty. He presented with intercostal nerve neuralgia and lung herniation accompanied by severe pain. Despite medication and lidocaine injections, there was no relief. Consequently, he underwent surgical treatment with IC for chronic MT wound pain and simultaneously underwent mesh repair for a lung hernia. He was discharged from hospital free of complications. Subsequently, he no longer required further pain medication and experienced a favorable recovery. Conclusion: Our findings suggest that concurrent IC and mesh repair can effectively relieve chronic post-MT intercostal nerve neuralgia and severe lung herniation pain in patients who underwent MT surgery, leading to a decrease in opioid medication usage. [ABSTRACT FROM AUTHOR]

Background: Mitral valve infective endocarditis (IE) still has a high mortality. Minimally invasive mitral valve surgery (MIMVS) is technically more challenging, especially in patients with endocarditis. Here, we compare the early postoperative outcome of patients with endocarditis and other indications for MIMVS. Methods: Two groups were formed, one consisting of patients who underwent surgery because of mitral valve endocarditis (IE group: n = 75) and the other group consisting of patients who had another indication for MIMVS (non-IE group: n = 862). Patients were observed for 30 postoperative days. Data were retrospectively reviewed and collected from January 2011 to September 2023. Results: Patients from the IE group were younger (60 vs. 68 years; p < 0.001) and had a higher preoperative history of stroke (26% vs. 6%; p < 0.001) with neurological symptoms (26% vs. 9%; p < 0.001). No difference was seen in overall surgery time (211 vs. 206 min; p = 0.71), time on cardiopulmonary bypass (137 vs. 137 min; p = 0.42) and aortic clamping time (76 vs. 78 min; p = 0.42). Concerning postoperative data, the IE group had a higher requirement of erythrocyte transfusion (2 vs. 0; p = 0.041). But no difference was seen in the need for a mitral valve redo procedure, bleeding, postoperative stroke, cerebral bleeding, new-onset dialysis, overall intubation time, sepsis, pacemaker implantation, wound healing disorders and 30-day mortality. Conclusions: Minimally invasive mitral valve surgery in patients with mitral valve endocarditis is feasible and safe. Infective endocarditis should not be considered as a contraindication for MIMVS. [ABSTRACT FROM AUTHOR]

We present 2 cases of patients with univentricular heart physiology of different anatomic variants who successfully underwent minimally invasive bidirectional cavopulmonary anastomosis via the right vertical axillary mini-thoracotomy. [ABSTRACT FROM AUTHOR]

Aim To compare outcomes of two different surgical techniques of coronary artery bypass grafting (CABG) for treating isolated left anterior descending (LAD) coronary artery disease by full median sternotomy technique vs. minimally invasive approach via left anterior mini-thoracotomy. Methods This retrospective, observational study, which included 61 elective patients, was conducted at the Clinic for Cardiovascular Surgery of the Clinical Centre of the University of Sarajevo in the period from June 2019 to January 2022. Patients were divided in two groups according to the operative technique used, the sternotomy CABG group of 30 patients where the access considered full median sternotomy, and the minimally invasive CABG group where left anterior mini-thoracotomy was performed. The groups were compared by previously defined primary and secondary clinical postoperative outcomes. Results Out of 61 patients, the majority was males, 50 (82%). The analysis of the outcomes of the minimally invasive CABG surgery showed significantly shorter operative times (p=0.001), less postoperative drainage (p=0.001) and transfusion requirements, shorter mechanical ventilation duration (p=0.0001), low major adverse cardiac and cerebrovascular events rates, as well as shorter Intensive Care Unit stay days with mean of 3.3±1.442 days (p=0.025), but no total hospital stay days with mean of 6.7±1.832 days (p=0.075) compared to sternotomy CABG group. Conclusion Minimally invasive approach for CABG surgery in treating isolated single vessel LAD disease, together with the fasttrack protocol, offers a reasonable alternative to full median sternotomy, leading to faster patients' overall recovery and improving the quality of life. [ABSTRACT FROM AUTHOR]

Consistent evidence recognizes minimally invasive valve surgery as the top-tier surgical approach for heart valve pathology. Conversely, the overall adoption of minimally invasive coronary surgery remains low. Notwithstanding, excellent clinical outcomes have been recently reported, further consolidating a technique that addresses major concerns associated with the traditional approach for the most frequently performed cardiac operation, including sternal dehiscence (i.e sternal sparing) and stroke (i.e. no-touch aorta), but that also guarantees a reduced resort to blood transfusions, diminished pain and faster recovery. More to the point, the suitability of minimally invasive strategies for combined coronary and valve procedures remains debateable. Almost no reports of such combined procedures are available in literature and the very few published experiences appear scarce and heterogeneous about the surgical access (i.e. single versus bilateral mini-thoracotomy). However, bilateral mini-thoracotomy has been proposed as a feasible and safe strategy for different cardiac operations like surgical ablation and left ventricular assist device implantation, but also for isolated multivessel minimally invasive coronary surgery. Here, we describe the feasibility of combined minimally invasive mitral valve and coronary surgery performed through bilateral mini-thoracotomy and we report outcomes of our initial series of 3 cases. [ABSTRACT FROM AUTHOR]

Background: Myocardial damage is an independent predictor of adverse outcome following cardiac surgery and myocardial protection is one of the key factors to achieve successful outcomes. Cardioplegia with Custodiol is currently the most used cardioplegia during minimally invasive cardiac surgery (MICS). Different randomized controlled trials compared blood and Custodiol cardioplegia in the context of traditional cardiac surgery. No data are available for MICS. Aim: The aim of this study was to compare the efficacy of cold blood versus Custodiol cardioplegia during MICS. Method: We retrospectively evaluated 90 patients undergoing MICS through a right mini-thoracotomy in a three-year period. Myocardial protection was performed using cold blood (44 patients, CBC group) or Custodiol (46 patients, Custodiol group) cardioplegia, based on surgeon preference and complexity of surgery. Results: The primary outcomes were post-operative cardiac troponin I (cTnI) and creatine kinase MB (CKMB) serum release and the incidence of Low Cardiac Output Syndrome (LCOS). Aortic cross-clamp and cardiopulmonary bypass times were higher in the Custodiol group. No difference was observed in myocardial injury enzyme release (peak cTnI value was 18±46 ng/ml in CBC and 21±37 ng/ml in Custodiol; p=0.245). No differences were observed for mortality, LCOS, atrial or ventricular arrhythmias onset, transfusions, mechanical ventilation time duration, intensive care unit and total hospital stay. Conclusions: Custodiol and cold blood cardioplegic solutions seem to assure similar myocardial protection in patients undergoing cardiac surgery through a right mini-thoracotomy approach. [ABSTRACT FROM AUTHOR]

Mitral annular calcification is a chronic and degenerative process of the fibrous base of the mitral valve. Surgical management of mitral valve dysfunction with severe annular calcification remains technically demanding and, to date, the preferred approach is still a standard full sternotomy. We aimed to analyze and report our experience with mitral valve surgery addressing annular calcification via the minimally invasive approach through a right mini-thoracotomy. Data of patients with mitral valve disease and underlying annular calcification undergoing minimally invasive surgery from 2018 to 2022 were prospectively collected and retrospectively analyzed. The severity of mitral annular calcification was categorized with an angio-computerized tomography scan analysis as mild, moderate or severe according to calcium thickness, calcium distribution, and trigone and leaflet involvement using the Mitral Annular Calcification Computerized Tomography-score. During the study period, 27 patients with mitral valve disease and associated mitral annular calcification were enrolled. The most common etiology was advanced Barlow's disease, which was encountered in 18 cases (67%). Mitral valve replacement was performed in 21 patients (78%). No intraoperative death, atrioventricular disruption, or circumflex coronary artery injury occurred. Conversion to sternotomy was necessary in a single case. Residual moderate periprosthetic leak requiring early reoperation and permanent heart block mandating permanent pacemaker implantation were reported in one and in three patients, respectively. No cases of stroke were reported. Two patients died, accounting for a 7.4% perioperative mortality. At a median follow-up of 9 months, one patient had residual moderate mitral regurgitation, whereas two patients required short-term reoperation and prosthetic valve (re)replacement. Minimally invasive mitral valve surgery via right mini-thoracotomy should be considered an and effective approach to be indicated also in patients with mild-to-severe mitral annular calcification. Routine angio-computerized tomography scan during work-up is a mandatory step to stratify the anatomical extension and severity of the mitral annular calcification. [ABSTRACT FROM AUTHOR]

Background: Redo mitral valve surgery by re-sternotomy approach has challenges such as bleeding and organ injury due to adhesion dissection, sternal bone infection, and poor field of view of mitral valve. On the other hand, redo mitral valve surgery via a right mini-thoracotomy approach appears to address these challenges. We successfully performed a double right mini-thoracotomies approach for mitral valve replacement and pseudoaneurysm repair under the beating-heart condition. Herein, we report the effectiveness and the safety of this technique and detailed procedure. Case presentation. The patient is a 71-year-old man with a history of Bentall procedure using a mechanical valve at another hospital 30 years ago. He developed acute heart failure due to severe mitral valve regurgitation. After medication, he was referred to our department for the purpose of surgery for mitral valve regurgitation. Preoperative transesophageal echocardiography showed extensive degenerative change of the both leaflets and chordae tendineae rupture at the P3 segment. Both left atrium and ventricle dilated, and left ventricle contractility reduced. Aortic mechanical valve had no problem. In addition, preoperative contrast enhanced computed tomography revealed a pseudoaneurysm at the distal anastomotic site of Bentall procedure. We performed mitral valve replacement by mechanical valve and repair of distal anastomotic cite under beating heart condition, utilizing a double right mini-thoracotomies approach for mitral valve and ascending aortic pseudoaneurysm respectively. The postoperative course was uneventful, the patient was discharged without complications. Conclusion: The right mini-thoracotomies approach efficiently accessed mitral valve and ascending aorta in reoperations, reducing the adhesion dissection risks and ensuring clear exposure. Moreover, concomitant use of beating-heart technique minimized adhesion dissection for aortic cross-clamp, preserved cardiac function. [ABSTRACT FROM AUTHOR]

Background: Aortic valve replacement by way of a right anterior mini-thoracotomy (RAMT) has shown excellent results in terms of mortality and morbidity. The aim of the present study was to compare RAMT aortic valve replacement (AVR) with conventional full sternotomy in regards to early perioperative outcomes and mortality.Methods: This was a retrospective, observational, cohort study of prospectively collected data from patients who underwent isolated, first time AVR between January 2013 and October 2016. Fifty-three RAMT patients were matched to a control group (conventional full sternotomy) using propensity score analysis.Results: The characteristics of the two cohorts were similar. The in-hospital mortality was 1.9% utilising the RAMT approach versus 5.7% using the sternotomy approach (p=0.34). Ventilation times were similar in both groups (7 [5-2] vs 8 [5-13] hrs; p=0.61). However, ICU length of stay was significantly longer in the RAMT group (median, 46.5 [23-59.5] vs 20 [14-23] hrs; p<0.001), which translated into a significantly longer postoperative hospital length of stay for the RAMT group (median, 8 [6-12] vs 6 [5.5-9.5] days; p=0.04) compared to the sternotomy group. RAMT was associated with a trend towards a higher incidence of postoperative AF in comparison to the sternotomy group, although this was not statistically significant (41.5% vs 28.3%; p=0.17). Patients in the RAMT group had lower 4-hour chest drain output (102.5 vs 1141ml; p=0.0.07). There was no statistically significant difference in rates of non-red cell transfusions between the two groups, (17%vs28.3%; p=0.10). The occurrence of stroke, re-exploration for bleeding, red-cell transfusion and wound infection was similar in both groups.Conclusions: Right anterior mini-thoracotomy in patients undergoing isolated aortic valve surgery is a safe approach in select patients, although associated with longer cardiopulmonary bypass times and ICU length of stay. [ABSTRACT FROM AUTHOR]

Background: The relationship between retrograde arterial perfusion and stroke in patients with peripheral vascular disease has been widely documented. Antegrade arterial perfusion has been favoured as an alternative approach in less invasive mitral valve (MV) operations. We aimed to analyse our experience in patients with peripheral arterial disease undergoing MV surgery through a right mini-thoracotomy adopting antegrade arterial perfusion.Method: A single-institution retrospective study on prospectively collected data was performed on patients undergoing right mini-thoracotomy MV surgery with antegrade arterial perfusion. Since 2009, indication for the latter was dictated by the severity of atherosclerotic burden. Preoperative screening included computed tomography, angiography, or both for the evaluation of the aorta and ileo-femoral arteries.Results: Consecutive patients (n=117) underwent MV surgery through a right mini-thoracotomy with antegrade arterial perfusion, established either by transthoracic central aortic cannulation in 65 (55.6%) cases or by axillary arterial cannulation in 52 (44.4%). Mean logistic EuroSCORE was 11%±2.3%. Twenty-five (25) (21.4%) patients had undergone one or more previous cardiac operations. Operative mortality was 4.3% (n=5). Nonfatal iatrogenic aortic dissection occurred in one case (0.8%). The incidence of stroke was zero.Conclusions: Axillary or central aortic cannulation is a promising alternative route to provide excellent arterial perfusion in right mini-thoracotomy MV surgery, with a very low incidence of stroke and other major perioperative complications in patients with severe aortic or peripheral arterial disease. [ABSTRACT FROM AUTHOR]

Objective: The goal of this manuscript was to report the clinical outcomes of the initial series of 100 consecutive Right Anterior Mini Thoracotomy (RAMT) aortic valve replacement (AVR) implantations at a Canadian Center.Methods: This retrospective study reported the clinical outcomes of the first 100 patients who underwent the RAMT approach for isolated surgical AVR in Calgary, Canada, between 2016 and 2020. Primary outcomes were death within 30 days of surgery and disabling stroke. Secondary outcomes included surgical times, the need for permanent pacemaker (PPM), incidence of postoperative blood transfusion in the intensive care unit (ICU), postsurgical atrial fibrillation (AF), length of ICU/hospital stay, postsurgical AF, residual paravalvular leak (PVL), postoperative transvalvular gradient, need for postsurgical intravenous opioids, duration of invasive ventilation in the ICU, and chest tube output in the first 12 h postsurgery.Results: In this study, 54 patients were male, and the average age of the cohort was 72 years. Mortality within 30 days of surgery was 1% with no disabling postoperative strokes. Mean cardiopulmonary bypass and cross clamp was 84 and 55 min, respectively. PPM rate was 3%, incidence of blood transfusion in the ICU was 4%, and the rate of postoperative AF was 23%. Median length of ICU and hospital stay was 1 and 5 days, respectively. Rate of mild or greater residual PVL was 3%, while the average residual transvalvular mean gradient was 8.5 mmHg.Conclusion: The sternum-sparing RAMT approach can be safely integrated into surgical practice as a minimally invasive alternative for isolated AVR, and can reduce postoperative bleeding and narcotic requirements. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to report the early outcomes of valvular heart surgeries performed via the right thoracotomy approach. While thoracotomy with femoro-femoral bypass is an established method for minimally invasive open-heart surgeries, thoracotomy with conventional cannulation is still being explored. In our center, we conducted 958 valvular heart surgery cases using the right anterolateral thoracotomy approach with central cannulation and data were analyzed. Methods: This is a retrospective observational study based on prospectively collected data from patients who underwent valvular heart surgery at our center spanning from April 2013 to April 2023. The data encompass demographics, procedures, operative techniques, post-operative morbidity, mortality, and a 1-month follow-up. Results: Our study revealed no procedure-related mortality. No patient required conversion to median sternotomy. Smooth cannulation and satisfactory exposure were achieved in all patients. The study encompassed a wide age range, from 14 to 68 years, with 618 female patients (64.5%) and 340 male patients (35.5%). The average cross-clamp time ranged from 38 to 90 min, the duration of cardio-pulmonary bypass ranged from 45 to 105 min, post-operative extubation ranged from 3 to 8 h, the average drain volume ranged from 100 to 350 ml, and the incision size ranged from 5 to 7 cm. Conclusions: Our data demonstrate that conventional cannulation via the right antero-lateral thoracotomy approach for valvular heart disease is a viable alternative to reduce the side effects associated with sternotomy and femoral cannulation. This procedure is safe, reproducible, and provides the same level of treatment quality. [ABSTRACT FROM AUTHOR]

Minimally invasive, sternum-sparing total coronary revascularization in multivessel disease via left anterior mini-thoracotomy (TCRAT) was introduced recently. Intra-aortic balloon occlusion is a conceivable option to avoid manipulation of the ascending aorta, to reduce the risk of stroke and to be able to treat patients with severe calcifications and unfavorable aortic anatomies. Background/Objectives: The aim of our study was to show that the use of the IntraClude® device, as part of minimally invasive coronary artery bypass grafting (CABG) via left anterior mini-thoracotomy, is feasible. Methods: From May to December 2023, CABG via left anterior mini-thoracotomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in 20 patients (17 male, 67.6 ± 8.2 (51–82) years). All patients had significant coronary artery disease (three-vessel: n = 6; two-vessel: n = 11; one-vessel: n = 3) with indication for surgical revascularization. The mean EuroScore2 was 2.6. Results: All patients successfully underwent minimally invasive CABG using endo-aortic balloon occlusion. A total of 43 distal anastomoses (2.2 ± 0.6 (1–3) per patient) were performed by using left internal artery mammary (n = 20) and radial artery (n = 14) for grafting the left anterior descending (n = 19), circumflex (n = 15) and right (n = 6) coronary artery. There was no hospital mortality, no stroke, no myocardial infarction or repeat revascularization. A total of 15 out of 20 patients left hospital within 8 days after surgery. Conclusions: TCRAT by using the IntraClude® device is feasible without compromising surgical principles while avoiding the external manipulation of the ascending aorta. The use of intra-aortic balloon occlusion instead of transthoracic clamps further reduces the invasiveness of the procedure. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive cardiac surgical techniques are increasingly applied in the treatment and management of a variety of adult ventricular septal defects (VSDs). However, repair of adult subarterial VSDs via left anterior mini-thoracotomy is rarely reported. The present study aimed to determine the feasibility and safety of the left anterior mini-thoracotomy for the repair of adult subarterial VSDs.Methods: Twenty-seven adult patients underwent repair of subarterial VSDs via left anterior mini-thoracotomy. The approach includes two options for skin incision access, longitudinal and transverse skin incisions. The skin incision length was 4.1-6.1 cm (mean, 5.1 ± 0.6 cm). The closure of the VSDs was obtained through the main pulmonary artery under direct visualization.Results: Successful repair of the defects was achieved in all the patients. No patients died or converted to median sternotomy. Average durations of cardiopulmonary bypass (CPB) and aortic cross-clamp were 102.5 ± 13.6 min (range, 85-127 min) and 54.6 ± 6.9 min (range, 45-66 min), respectively. No patients required blood transfusion. The average postoperative hospital stay was 5.1 ± 0.7 days (range, 4-6 days). There were no postoperative complications related to the operative procedures or peripheral cannulation. During the follow-up of 5.4-32.3 months, no patients were found to have residual shunt, wound infections, pericardial effusion, neurologic or other complications.Conclusion: Our experiences demonstrate that minimally invasive cardiac surgical technique via left anterior mini-thoracotomy can be served as a novel, feasible and safe alternative for the repair of adult subarterial VSDs. [ABSTRACT FROM AUTHOR]

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]

Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and– when possible–the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective. [ABSTRACT FROM AUTHOR]

Background: Patients can develop de novo malignancies following orthotopic heart transplantation. However, vascular tumors are not commonly described in this population. Case presentation: We present a 69-year-old female with a history of orthotopic heart transplantation for chemotherapy-induced cardiomyopathy who developed an incidental pulmonary artery mass six years after her transplantation. Given concerns for malignancy, the patient underwent an operative excisional biopsy through a left anterior mini-thoracotomy with femoral artery and vein cannulation for cardiopulmonary bypass. The mass was determined to be a non-malignant vascular overgrowth with PIK3CA mutation. Conclusion: We present the case of an unusual pulmonary artery mass with PIK3CA mutation found in a post heart transplant patient. We were able to spare her the morbidity of a redo-sternotomy by excising the mass via a minimally invasive left anterior thoracotomy approach. [ABSTRACT FROM AUTHOR]

In recent years, there has been a growing interest in robotic-assisted coronary artery revascularization in Europe. Two different types of surgery can be performed using a robotic platform: RA-MIDCAB, in which the mammary artery is harvested endoscopically with robotic assistance and off-pump bypass graft is achieved under direct vision through mini thoracotomy, and TE-CAB, completely robotically performed. We started the robotic cardiac surgery program for mitral valve disease in our hospital, Humanitas Gavazzeni (Bergamo, Italy), in 2019; and in 2021, we addressed our experience with RA-MIDCAB. After a learning curve period, we have developed our technique to optimize the benefits offered by the robotic platform, tailoring strategy to individual patients, based on preoperative radiological images. [ABSTRACT FROM AUTHOR]

Background: The small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy.Methods: We retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared.Results: Of the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67-113) minutes; vs. 117 (93.5-139.5); vs. 102.5 (85.5-132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5-9) days; vs. 7 (5-14.5); vs 9 (6-15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)].Conclusions: Minimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy. [ABSTRACT FROM AUTHOR]

Background: Although minimally invasive coronary artery bypass grafting (MICS-CABG) has been shown to result in excellent clinical outcomes overall adoption rates still remain low. Traditional strategies for minimally invasive multivessel revascularization - usually performed through single-thoracotomy - have to deal with restricted grafting possibilities and possible increased susceptibility of arterial grafts to competitive flow, restraining their applicability to very specific indications or hybrid approaches and on top, are prone to conversion to full-sternotomy in case of left internal thoracic artery (LITA) insufficiency.Methods: Here, we present a novel alternative to the traditional MICS-CABG approaches by adding a right-sided upper "half-mini-thoracotomy", which allows for aortocoronary bypass grafting in standard "off-pump" manner and adoption of similar revascularization principles as with conventional CABG during minimally invasive multivessel revascularization, though reducing restrictions inherent to current MICS-CABG strategies.Results: So far, feasibility and safety of this new approach has been successfully shown in 7 consecutive patients requiring surgical revascularization with no procedure-specific complications and graft configuration as well as intraoperative flow assessment comparable to those of similar patients operated via standard full-sternotomy off-pump coronary artery bypass (OPCAB) surgery.Conclusions: Further evaluation warranted, this technique might have the potential to develop into an additional approach for minimally invasive multivessel revascularization, especially in cases where competitive flow to arterial grafts is feared, while also serving as a bailout-strategy for traditional approaches in case of LITA insufficiency. [ABSTRACT FROM AUTHOR]

In the last decades, minimally invasive procedures have been developed in the therapy of aortic valve disorders. Recently, a novel concept of minimally invasive coronary revascularization in multivessel disease via left anterior mini-thoracotomy demonstrated promising results. Full median sternotomy, as a very invasive procedure, is the standard approach in concomitant surgical aortic valve replacement (sAVR) and coronary bypass grafting (CABG). The aim of our study was to show that the combination of minimal invasive aortic valve replacement via upper mini-sternotomy and coronary artery bypass grafting via left anterior mini-thoracotomy is feasible to avoid full median sternotomy. From 07/2022 to 09/2022, concomitant sAVR via upper partial sternotomy and CABG via left anterior mini-thoractomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in six consecutive patients (6 males; 69.8 ± 7.4 [60–79] years). All patients had severe aortic stenosis (MPG 45.5 ± 17.3 mmHg) and a significant coronary artery disease (three-vessel: 33%, two-vessel: 33%, one-vessel: 33%) with indication to cardiac surgery. Mean EuroScore2 was 3.2. All patients underwent successful less invasive concomitant biological sAVR and CABG. 67% of patients received a 25 mm, 33% received a 23 mm biological aortic valve replacement (Edwards Lifesciences Perimount). A total of 11 distal anastomoses (1.8 ± 1.0 [1–3] per patient) were performed by using left internal artery mammary (50%), radial artery (17%) and saphenous venous graft (67%) for grafting the left anterior descending (83%), circumflex (67%) and right (33%) coronary artery. Hospital mortality was 0%, stroke rate was 0%, myocardial infarction was 0% and repeat revascularization rate was 0%, ICU stay was 1 day in 83% of all patients and 50% left hospital within 8 days after surgery. Less invasive concomitant surgical aortic valve replacement and coronary artery bypass grafting using upper mini-sternotomy and left anterior mini-thoracotomy is feasible without compromises in surgical principles and complete coronary revascularization while maintaining thoracic stability by avoiding full median sternotomy. [ABSTRACT FROM AUTHOR]

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis. [ABSTRACT FROM AUTHOR]

BACKGROUND Mean age of patients with valves diseases is significantly increasing, and, in the near future, cardiac surgeons will have to deal with a considerable number of patients aged more than 80 years. The remarkable results gained by the minimally invasive approach have encouraged its application in more complex and fragile patients, such as older people. This study aimed to identify the rate of early mortality and major complications, and independent predictors for mid-term mortality in octogenarians undergoing minimally invasive valve surgery. METHODS Octogenarian patients undergoing right mini-thoracotomy mitral and/or tricuspid valve surgery between 2006 and 2020 were included. Primary endpoint was to identify independent predictors for mid-term mortality, and secondary endpoints were operative morality, stroke, independent predictors for early composite outcome, and quality of life at follow-up. RESULTS Analysis was performed on 130 patients. Stroke occurred in one patient (0.8%), while operative mortality was 6% (eight patients). One-year and five-year survival were 86% and 64%, respectively. Logistic regression identified age and creatinine level as independent predictors of mid-term mortality, survival analysis showed that age ≥ 84 years and creatinine level ≥ 1.22 mg/dL were the cut-off points for worst prognosis. Female gender and hypertension were found to be independent predictors of early composite outcome. CONCLUSIONS Results of the present study show that age alone should not be considered a contraindication for minimally invasive valve surgery. Identifying patients who are most likely to have survival and functional benefits after surgery is decisive to achieve optimal health outcomes and prevent futile procedures. [ABSTRACT FROM AUTHOR]

We report a case of a 74-year-old man with diagnosis of concomitant primary cardiac tumor and right upper lobe of lung cancer. Both tumors were evaluated to be resectable with no further metastasis. A one-stage resection of both tumors through right mini-thoracotomy with endoscopic assistance was performed. The cardiac tumor resection during cardiopulmonary bypass was performed first, followed by right upper lobectomy and lymph nodes dissection with the same incision and position. Short-term results were satisfying and previous literature was reviewed to evaluate this method. [ABSTRACT FROM AUTHOR]

Objective: The use of minimally invasive or transcatheter interventions rather than standard full sternotomy operations to treat tricuspid valve (TV) disease is increasing. The debate however is still open regarding venous drainage management during cardiopulmonary bypass (CPB) and wheatear or not superior and inferior vena cava should be occluded during the opening of the right atrium to avoid air entrance in the venous line. The aim of the present study is to report operative outcomes and midterm follow-up results of minimally invasive TV surgery performed without caval occlusion.Methods: A retrospective outcome evaluation from institutional records was performed with prospective data entry. Considered were consecutive patients who underwent right mini-thoracotomy TV surgery isolated or combined with mitral valve surgery during the period from June 2013 to February 2020. A telephone and echocardiographic follow-up was performed.Results: During the study period, 68 consecutive patients underwent minimally invasive TV surgery without occlusion of cava veins. The mean age was 69 ± 14 years and 48 (70%) were female. All operations were performed safely without air-lock during CPB. A perioperative cerebral stroke occurred in one patient. The survival at a 5- and 8-year follow-up was 100% and 79%, respectively. No severe tricuspid regurgitation was evident at echocardiographic follow-up.Conclusion: Our results show that performing tricuspid surgery without caval occlusion is safe. The air was captured by the active vacuum drainage system without causing damage. Midterm follow-up data confirm that a minimally invasive approach does not alter the quality of surgery. [ABSTRACT FROM AUTHOR]

Minimally invasive cardiac surgery (MICS) via right lateral mini thoracotomy is the gold standard treatment approach for mitral and tricuspid valve disorders. Other selected procedures (e.g. transapical aortic valve implantation, MIDCAB) require a left lateral mini thoracotomy for surgical access. Advantages of MICS over complete sternotomy are well known, but access-related complications post MICS, such as pulmonary herniation, are often underestimated/overlooked. In males, a pulmonary herniation in the proximity of the former thoracotomy is often clinically visible, especially when the intrathoracic pressure rises (e.g. during coughing). In females, clinical symptoms may be hidden by the breast and patients often have unspecific complaints or occasional pain when coughing, making identification of a lung herniation more difficult. Chest computed tomography is the diagnostic tool of choice for pulmonary herniations. Using a series of 20 patients with pulmonary herniation post MICS, we report our findings in diagnosis and treatment of this condition. [ABSTRACT FROM AUTHOR]

Introduction: It is not yet clear whether cardiac surgery by mini-incision (minimally invasive cardiac surgery [MICS]) is overall less painful than the conventional approach by full sternotomy (FS). A meta-analysis is necessary to investigate polled results on this topic. Methods: PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05). Results: In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95). Conclusion: MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision. [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]

In this work we aimed to evaluate the evolution of our surgical experience with the implantation of a continuous flow left ventricular assist device (LVAD), from the original full sternotomy approach to less invasive surgical strategies including mini‐sternotomy and/or mini‐thoracotomies. We reviewed all consecutive patients implanted with a continuous flow LVAD at our Institute. To exclude the possible bias related to the device used, out of 91 collected LVADs implants, we selected only those patients (n = 42) who received, between 2012 and 2015, the HeartWare HVAD. The analysis focused on the surgical approach used for the LVAD implant. Most of the patients (95%) were affected by dilated or ischemic cardiomyopathy, with an INTERMACS class I‐II in the majority of cases (77%). The LVAD implant was performed through a full sternotomy in 10 patients (24%); the remaining 32 cases (76%) were managed with minimally invasive procedures. These were left mini‐thoracotomy with upper mini‐sternotomy (20 patients, 62%), right and left mini‐thoracotomy (7 patients, 22%), and a recently developed left mini‐thoracotomy with outflow graft anastomosis to the left axillary artery (5 patients, 16%). The most common adverse event on device was right heart failure (26%). Eighteen patients (43%) were transplanted. Overall estimated 24 months survival (on device or after transplant) was 68 ± 7%. The causal analysis, adjusted by propensity score weighting baseline data and sample size, showed that left mini‐thoracotomy with outflow anastomosis to the left axillary artery resulted in a significantly reduced rate of post implant right heart failure (P < 0.01), and mechanical ventilation time (P = 0.049). To conclude, in our series, by applying mini‐invasive implant techniques in the majority of cases, mid‐term survival of continuous flow LVADs in severely compromised patients was satisfactory. In the adjusted analysis, the left anterior mini‐thoracotomy with outflow anastomosis to the left axillary artery showed the most favorable results. [ABSTRACT FROM AUTHOR]

Background: Several surgical techniques have been proposed to repair right partial anomalous pulmonary venous connection (PAPVC) along with sinus venosus defect (SVD). This study aimed to compare the perioperative data and outcomes of double‐patch repair using a minimally invasive approach versus conventional sternotomy in pediatric and adult patients. Methods: This retrospective study was conducted on 48 minimally invasive cases and 35 sternotomy cases, undergoing surgery by a single surgeon between July 2002 and August 2020. For all patients, repair was performed using the double‐patch technique. In the minimally invasive approach, right mini‐thoracotomy was performed with central cannulation for children and with peripheral cannulation for adults. The patients were classified into two pediatric and adult groups, and each group was categorized into minimally invasive and sternotomy approaches. They were followed‐up by transthoracic echocardiography and electrocardiography before and early after surgery, 3 and 6 months after surgery, and then annually. The relative data were compared between the two approaches in terms of perioperative findings, postoperative pulmonary vein or superior vena cava (SVC) stenosis, and sinus node dysfunction. Results: This study included 25 minimally invasive cases and 19 sternotomy cases in the pediatric group (mean age, 4.99 ± 4.28 and 6.10 ± 4.39 years, respectively) and 23 minimally invasive cases and 16 sternotomy cases in the adult group (mean age, 35.73 ± 8.06 and 32.62 ± 9.80 years, respectively). The mean and median follow‐ups were 6.31 ± 4.92 years and 6 years (range: 6 month−18 year) in the pediatric group and 6.15 ± 4.53 years and 5 years (range: 6 month−18 year) in the adult group, respectively. The mean chest tube drainage was significantly lower in the minimally invasive pediatric group (p =.03), and the mean blood transfusion volume was significantly lower in the minimally invasive adult group compared to the other groups (p =.03). No stenosis occurred in the pulmonary veins. Mild SVC stenosis occurred in one patient in the minimally invasive pediatric group, with no need for reintervention. All patients had a normal sinus rhythm, except for the mentioned case with a transient, first‐degree atrioventricular block, which spontaneously reverted to the normal sinus rhythm. Conclusions: The minimally invasive approach can be a safe and practical alternative for the double‐patch repair of PAPVC and SVD. It ensures a repair with comparable quality to sternotomy, but with better cosmetic and psychological outcomes. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive mitral valve repair (MVr) is commonly performed. Data on the outcomes of robotic MVr versus nonrobotic minimally invasive MVr are lacking. We sought to compare the short-term and mid-term outcomes of robotic and nonrobotic MVr.Methods: We reviewed all patients who underwent robotic MVr (n = 424) or nonrobotic MVr via right mini-thoracotomy (n = 86) at Mayo Clinic, Rochester, MN, from January 2015 to February 2020. Data on baseline and operative characteristics, operative and long-term outcomes were analyzed. Patients were matched 1:1 using propensity scores.Results: Sixty-nine matched pairs were included in the study. The median age was 59 years (interquartile range [IQR]: 54-69) and 75% (n = 103) were male. Baseline characteristics were similar after matching. Robotic and nonrobotic MVr had similar operative characteristics, except that robotic had longer cross-clamp times (57 [48-67] vs. 47 [37-58] min, p < .001) and more P2 resections (83% vs. 68%, p = .05) compared to nonrobotic MVr. There was no difference in operative outcomes between groups. Hospital stay was shorter after robotic MVr (4 [3-4] vs. 4 [4-6] days, p = .003). After a median follow-up of 3.3 years (IQR, 2.1-4.5), there was no mortality in either group, and there was no difference in freedom from mitral valve reoperations between robotic and nonrobotic MVr (5 years: 97.1% vs. 95.7%, p = .63). Follow-up echocardiogram analysis predicted excellent freedom from recurrent moderate-or-severe mitral regurgitation at 3 years after robotic and nonrobotic MVr (90% vs. 92%, p = .18, respectively).Conclusions: Both short-term and mid-term outcomes of robotic and nonrobotic minimally invasive mitral repair surgery are comparable. [ABSTRACT FROM AUTHOR]

The present case report concerned a young woman who had a ventricular septal defect (VSD) that was unable to be closed by interventional approach. She had successfully undergone an anterior mini-thoracotomy to close the VSD directly. The thoracotomy approach was chosen as it would give a better cosmetic result for this patient without any subordination in comparison with the standard sternotomy approach. This is the first reported case of minimally invasive VSD closure via the right thoracotomy approach in Thailand. [ABSTRACT FROM AUTHOR]

Background and objectives: Certain clinical and anatomical conditions are absolute or relative contraindications for safe mitral valve surgery via the right mini-thoracotomy access. It is uncertain whether patients with these contraindications may benefit from the less invasive approach via upper hemi-sternotomy compared to standard full sternotomy. Materials and methods: Out of 2052 mitral valve surgery patients, operated from 6/04 through 2/19, 1535 were excluded due to the different criteria for eligibility to both approaches. Out of these, 350 received full sternotomy and 167 upper hemi-sternotomy. After propensity score matching, 164 pairs were analyzed for operative variables, postoperative complications and 30-day and one-year survival. Results: Upper hemi-sternotomy was associated with a survival benefit of 30 days (99.4% vs. 82.1%; p < 0.001) and one-year (93.9% vs. 79.9% p < 0.001, HR 0.26, 95% CI 0.14–0.49). Cardiopulmonary bypass and aortic cross-clamp times were comparable in both groups. Upper hemi-sternotomy resulted in less low cardiac output syndrome (18.9% vs. 31.1%; p = 0.011); ventilation time (8 vs. 13 h; p < 0.001), length of intensive care stay (1 vs. 2 days; p < 0.001) and total hospital stay (8 vs. 9 days; p < 0.001) were shorter in the upper hemi-sternotomy group. Conclusion: In patients undergoing mitral valve surgery, upper hemi-sternotomy is associated with short- and mid-term survival benefits as well as lower postoperative complication rates compared to full sternotomy. Hence, the less invasive upper hemi-sternotomy can be a valid approach in patients with contraindications for right mini-thoracotomy. [ABSTRACT FROM AUTHOR]

Background: Spinal nerve block is difficult with minimally invasive cardiac surgery (MICS), because of the risk of serious bleeding complications due to full heparinization. Continuous extrapleural intercostal nerve block (CEINB) is a postoperative pain treatment for intercostal thoracotomy, with fewer complications. Here, we report a case in which imaging evaluation of CEINB with contrast medium was conducted to anatomically confirm the spread of local anesthetics after MICS. Case presentation: A 65-year-old woman with severe mitral regurgitation underwent mitral valve plasty under general anesthesia via right-sided mini-thoracotomy. A CEINB catheter was placed before the incision was closed, without creating a conventional extrapleural pocket. We conducted an imaging evaluation with a contrast medium via the inserted catheter and confirmed sufficient spread around the intercostal nerve area. In addition, postoperative pain was well controlled by the nerve block. Conclusions: Imaging evaluation of CEINB with contrast medium could increase analgesic quality and decrease complications post-MICS. [ABSTRACT FROM AUTHOR]

Objective: Aortic valve disease is the most common heart disease in the elderly calling for replacement with an artificial valve. The presented surgical robot aims to provide a highly controllable instrument for efficient delivery of an artificial valve by the help of integrated endoscopic vision. Methods: A robot (called ValveTech), intended for minimally invasive surgery (MIS) and consisting of a flexible cable driven manipulator, a passive arm, and a control unit has been designed and prototyped. The flexible manipulator has several features (e.g., stabilizing flaps, tiny cameras, dexterous introducer and custom cartridge) to help the proper valve placement. It provides 5 degrees of freedom for reaching the operative site via mini-thoracotomy; it adjusts the valve and expands it at the optimal position. The robot was evaluated by ten cardiac surgeons following a real surgical scenario in artificial chest simulator with an aortic mockup. Moreover, after each delivery, the expanded valve was evaluated objectively in comparison with the ideal position. Results: The robot performances were evaluated positively by surgeons. The trials resulted in faster delivery and an average misalignment distance of 3.8 mm along the aorta axis; 16.3 degrees rotational angle around aorta axis and 8.8 degrees misalignment of the valve commissure plane to the ideal plane were measured. Conclusion: The trials successfully proved the proposed system for valve delivery under endoscopic vision. Significance: The ValveTech robot can be an alternative solution for minimally invasive aortic valve surgery and improve the quality of the operation both for surgeons and patients. [ABSTRACT FROM AUTHOR]

Background: Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. Methods: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. Results: A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. Conclusion: This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research. [ABSTRACT FROM AUTHOR]

Background: Pericardial cysts, though rare and benign, can present with various clinical symptoms depending on their size and location in the body. The detection of these cysts typically relies on imaging studies for a conclusive diagnosis, with surgical removal being the definitive treatment. Case presentation: This case report details the clinical journey of a 32-year-old Iranian woman with a family history of breast and lung cancer, who experienced left-sided chest pain. Utilizing a combination of clinical history review, mammography, echocardiography, and computed tomography, a precise diagnosis of a 10 cm × 3.5 cm pericardial cyst was achieved. The patient underwent median sternotomy for complete cyst excision. Conclusions: While pericardial cysts are often asymptomatic and benign, they can lead to life-threatening complications. Hence, regular follow-up is advised, and in certain instances, minimally invasive interventions or surgery may be necessary. [ABSTRACT FROM AUTHOR]

Objective: Renal dysfunction and acute renal failure after coronary artery bypass grafting (CABG) are among the main causes of increased mortality and morbidity. A sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced with promising early and midterm outcomes in multivessel coronary artery disease. There are limited data regarding renal complications in patients undergoing the TCRAT technique. The present study analyzed renal outcomes in TCRAT compared to CABG via full median sternotomy (FS). Methods: We analyzed the records of 227 consecutive TCRAT patients (from September 2021 to June 2023) and 228 consecutive FS patients (from January 2017 to December 2018) who underwent nonemergent CABG. Following propensity score matching, preoperative baseline characteristics—including age, sex, diabetes mellitus, arterial hypertension, left ventricular ejection fraction, EuroSCORE II, preoperative serum creatinine, estimated glomerular filtration rate (eGFR), serum urea, and pre-existing chronic renal insufficiency—were comparable between the TCRAT (n = 170) and the FS group (n = 170). The examined postoperative renal parameters and complications were serum creatinine, eGFR, and serum urea on the first postoperative day. Moreover, serum creatinine, eGFR and serum urea at the time of discharge, postoperative ARF, and hemodialysis were investigated. Additionally, the duration of operation, CPB time, aortic cross-clamp time, ICU and hospital stay, ECMO support, rethoracotomy and in-hospital mortality were analyzed. The parameters were compared between groups using a Student's t-test or Mann–Whitney U test. Results: The duration of operation (332 ± 66 vs. 257 ± 61 min; p < 0.05), CPB time (161 ± 40 vs. 116 ± 38 min; p < 0.05), and aortic cross-clamp time (100 ± 31 vs. 76 ± 26; p < 0.05) were longer in the TCRAT group. ICU (1.8 ± 2.2 vs. 2.9 ± 3.6 days; p < 0.05) and hospital (10.4 ± 7.6 vs. 12.4 ± 7.5 days; p < 0.05) stays were shorter in the TCRAT group. There were no differences between groups with regard to the renal parameters examined. Conclusions: Despite a prolonged duration of operation, CPB time, and aortic cross-clamp time when using the TCRAT technique, no increase in renal complications were found. In addition, ICU and hospital stays in the TCRAT group were shorter compared to CABG via full median sternotomy. [ABSTRACT FROM AUTHOR]

This study evaluates the long-term outcomes of minimally invasive mitral valve repair (MIMVR) in patients with degenerative mitral regurgitation, focusing on survival, mitral valve repair failure, and re-operation rates. A cohort of patients undergoing three primary repair techniques—quadrangular resection, edge-to-edge repair, and artificial chordae implantation—was analyzed using time-to-event methods. The overall survival rates at 1, 10, and 20 years were high and comparable among the techniques, indicating effective long-term benefits of MIMVR. However, freedom from recurrence of moderate mitral regurgitation (MR) ≥ 2 was significantly higher in the quadrangular resection and edge-to-edge groups compared to the artificial chordae group. No significant differences were observed for recurrent MR ≥ 3. Re-operation rates were low and similar across all techniques, underscoring the durability of MIMVR. Pre-discharge residual MR ≥ 2 was identified as a strong predictor of long-term repair failure. These findings confirm the effectiveness of MIMVR, with all techniques demonstrating excellent long-term survival and durability. [ABSTRACT FROM AUTHOR]

Introduction: Minimally invasive mitral valve surgery (MIMVS) has become a widely accepted alternative to the standard sternotomy approach for treatment of mitral valve (MV) disease. Because the extent and location of mini-thoracotomies employed for MIMVS vary from center to center, the conclusions regarding superior cosmesis are not generalizable. The totally thoracoscopic periareolar (TTP) - MIMVS technique has been used at our department for minimally invasive cardiac surgery since 2015. Aim: To report early surgical data as well as mid-term outcomes in patients undergoing TTP-MIMVS. Material and methods: Between 2015 and 2017, 48 consecutive patients (mean age: 65.4 ±10; 83% men; Euro- SCORE II: 5.1 ±4%) underwent TTP-MIMVS due to mitral and mitral/tricuspid valve (TV) disease; patients' demographics and clinical outcomes were prospectively collected. Kaplan-Meier estimates of survival and freedom from re-intervention were analyzed as well. Results: Mean follow-up was 1.7 (max 2.5) years. Of 48 patients, 33 (69%) underwent isolated MV repair, 4 (8%) isolated MV replacement and 11 (23%) MV/TV repair. The cardiopulmonary bypass and aortic cross-clamp time was 166 ±70 and 103 ±39 min respectively. There was no conversion to either full sternotomy or a mini-thoracotomy approach. Median (interquartile range) duration of intensive care unit stay was 1.2 (1.0-2.0) days. There was one in-hospital death (2.1%) in the TTP-MIMVS group. No strokes or wound infections were observed. Within the investigated follow-up, the freedom from reoperation rate was 96.4%; remote survival was estimated at 96.9%. Conclusions: The study proved that TTP-minimally invasive surgery was safe and feasible in mitral and tricuspid valve surgery. It has been associated with superior esthetics. Mitral repairs performed through TTP access are durable in mid-term observation. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to compare the cases of minimally invasive mitral valve surgery (MICS-mitral) performed using right mini-thoracotomy (RT) with those performed using median sternotomy (MS). Methods: Between 2008 and 2012, 6137 patients underwent isolated mitral valve repair at 210 institutions and were registered in the Japan Adult Cardiovascular Surgery Database. We compared 756 who underwent MICS-mitral via RT to 5381 MS patients and performed a one-to-one matched analysis based on the estimated propensity score. Results: The in-hospital mortality was similar between both groups (RT vs. MS: 0.5 vs. 1.1 %). Although the incidence of postoperative stroke, renal failure, and prolonged ventilation was similar, the number of patients with mediastinitis was greater in the MS group (RT vs. MS: 0 vs. 0.7 %, p < 0.01). Reexploration for bleeding was more frequent in the RT group (RT vs. MS: 2.9 vs. 1.4 %, p < 0.01). Mortality and morbidity occurred at a higher rate in low-volume institutions. The propensity analysis showed that the operation-related times were significantly longer in the RT group, while the length of hospital stay was shorter. In a propensity analysis of patients <60 years of age, there was no in-hospital mortality. Conclusions: MICS-mitral via RT was successful without compromising the clinical outcomes. Although the operation time and postoperative bleeding should be improved, an RT approach is safe in appropriately selected patients, especially those <60 years of age or treated in a high-volume center. [ABSTRACT FROM AUTHOR]

Background: Globally, the utilisation of minimally invasive techniques has become increasingly prevalent. While traditional open-heart procedures still dominate the landscape, a significant portion of cardiac surgeries are now performed minimally invasively. The aim of this study is to provide an insightful overview of the current state of minimally invasive cardiac surgery in Africa. Main body: A comprehensive database search was performed on PubMed, African Journal Online, Google Scholar, and Scopus to identify published data reporting on outcomes of minimally invasive cardiac surgery in Africa, from inception till June 2024. We used the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines to undergo this study. The primary outcomes of interest were in-hospital mortality and overall mortality. Data were pooled together and analysed using a random effect model for meta-analysis with R software. Out of a total of 2309 articles identified, only fourteen papers met our inclusion criteria following deduplication and screening. The four countries with published research include Egypt, South Africa, Tanzania, and Morocco, with a total sample size of 1357 patients. The meta-analysis of the reported outcomes produced a pooled in-hospital mortality prevalence of 1.18%, while the pooled overall mortality prevalence was 2.23%. There was no statistically significant difference in outcomes between the mini sternotomy and the full sternotomy group. Conclusion: The pooled outcomes of minimally invasive cardiac surgery in Africa are comparable to those in other regions. However, there are several socio-economic factors limiting its widespread practice in Africa. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Serratus posterior intercostal plane block (SPSIPB) is a novel periparavertebral block. It provides anterolateral posterior chest wall analgesia. It is an interfascial plane block, performed under ultrasound guidance, and the visualization of landmarks is easy. It is performed deep into the serratus posterior superior muscle at the level of the third rib. Until now, there have been case reports about the usage of single-shot SPSIPB, but there are no reports about the usage of the block catheterization technique of SPSIPB. Continuous infusion from a catheter of interfascial plane blocks is important for postoperative analgesia management after painful surgeries such as thoracic and cardiac surgeries. Thus, we performed SPSIPB catheterization in a patient who underwent right atrial mass excision with minimally invasive thoracotomy surgery. Here, we present our successful analgesic experience with continuous SPSIPB in this case report. [ABSTRACT FROM AUTHOR]