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Abstract Introduction Pulmonary regurgitation (PR) remains a common sequela in patients following surgically corrected TOF, and may lead to progressive right ventricle dilatation and dysfunction. The conventional approach of redo-sternotomy for pulmonary valve replacement (PVR) is associated with increased operative time as well as risks of bleeding and injury to the heart and great vessels. Thus, left anterior mini-thoracotomy has become an alternative approach in eliminating the risks of redo-sternotomy in these patients. This series aimed to determine the outcomes of minimally invasive pulmonary valve replacement after surgical TOF correction. Methods A retrospective analysis was conducted on 24 patients with severe PR post-surgical TOF correction who underwent left anterior mini-thoracotomy PVR in Penang General Hospital from January 2021 to January 2023. Results The median age was 23.5 years (I.Q.range 17.6-36.3), with a male:female ratio of 1:4. Majority of patients had mild to moderate symptoms prior to surgery and 19 patients (79.1%) were on regular diuretics medication. All patients had severe free-flow PR with evidence of right ventricular dilatation and dysfunction. Magnetic Resonance Imaging and computed tomography of pulmonary artery were performed prior to surgery. Minimally invasive PVR was performed on all patients via left upper anterior mini-thoracotomy and femoral-femoral bypass without cardioplegic arrest. The operative time and cardiopulmonary bypass time were 208 (I.Q.range 172-324) and 98.6 minutes(I.Q.range 87.4-152.4) respectively. The time to wean off inotropes postoperatively was 6.2 hours (I.Q.range1.4-14.8), and no postoperative arrhythmia and chest re-exploration were reported. Most patients stayed in Intensive Care Unit (ICU) for 10.8 hours (I.Q.range 8.4-36.5), and the total hospital stay was 4.2 days (I.Q.range 3.4-7.6). 2 patients (11.1%) required blood transfusion postoperative. There was no paravalvular leak and no mortality during the follow-up period of up to 28 months. Conclusion Minimally invasive PVR after surgical correction of TOF is a safe alternative to the conventional redo-sternotomy approach in patients with favorable anatomy. This approach is able to reduce the risks associated with redo-sternotomy, particularly bleeding and injury to mediastinal structures, with the additional benefit of expedited recovery and hospital discharge. Our series has shown a safe and efficient approach in these patients with favorable outcomes.

BackgroundRight anterior mini thoracotomy (RAMT) for aortic valve replacement (AVR) is a minimally invasive procedure that avoids sternotomy. Herein, we report the outcomes of patients who underwent redo-cardiac via a RAMT approach for AVR.MethodsThis case series reports the clinical outcomes of 14 consecutive redo operations, done in Calgary (Canada) and Gdansk (Poland) between 2020 and 2023. Primary outcomes were 30-day mortality and disabling stroke. Secondary outcomes included surgical times, hemodynamics, permanent pacemaker implantation (PPM), length of ICU and hospital stay, new post-operative atrial fibrillation (POAF), post-operative blood transfusion, incidence of acute respiratory distress syndrome (ARDS), rate of continuous renal replacement therapy (CRRT) and/or dialysis, and chest tube output in the first 12-hours after surgery.ResultsNine patients were male, and the mean age was 64.36 years. There were no deaths, while one patient had a disabling stroke postoperatively. Mean cardiopulmonary bypass and cross clamp-times were 136 min and 90 min, respectively. Three patients needed a PPM, 3 patients needed blood transfusions, and 2 developed new onset POAF. Median lengths of ICU and hospital stays were 2 and 12 days, respectively. There was no incidence of paravalvular leak greater than trace and the average transvalvular mean gradient was 12.23 mmHg.ConclusionThe number of patients requiring redo-AVR is increasing. Redo-sternotomy may not be feasible for many patients. This study suggests that the RAMT approach is a safe alternative to redo-sternotomy for patients that require an AVR.

Abstract Background Aortic regurgitation with dilated annulus presents a technical challenge for conventional transcatheter aortic valve implantation (TAVI) procedures. Case presentation We report a case of an 84-year-old frail patient with a history of breathlessness found to have severe aortic regurgitation and moderately impaired left ventricular systolic function. The patient underwent a successful TAVI procedure using the XL-Myval 32 mm transcatheter heart valve (THV) via an anterior right mini-thoracotomy with a direct aortic approach. The patient recovered well post-operatively with good hemodynamic resolution. Conclusions This first in human case highlights the efficacy and potential of applying innovative approaches, such as the new sizes of Myval THV and direct aortic access via anterior right mini thoracotomy, in addressing challenging anatomical variations in TAVI procedures with good outcome.

Abstract Aortic valve replacement (AVR) is a critical procedure for patients with aortic valve diseases. This study compares the effectiveness of three minimally-invasive surgical approaches for AVR: totally thoracoscopic (TT), right anterior mini-thoracotomy, and upper mini-sternotomy. We analyzed retrospective data from 130 patients who underwent one of these surgeries, focusing on various factors such as duration of hospital stay, operation time, times for cardiopulmonary bypass and aortic cross-clamping, postoperative complications, levels of cardiac biomarkers, pain intensity using the Visual Analog Scale, and mid-term survival rates. Results show that while the TT method had the longest operation times, it also had the shortest hospital stays and faster pain reduction post-surgery. Although the TT group initially showed higher cardiac biomarker levels after surgery, these levels normalized by the third day, similar to the other groups. There were no significant differences in mid-term survival and major adverse cardiac and cerebrovascular event (MACCE) rates among the groups. These findings suggest that the TT method, despite longer surgical times, offers a quicker initial recovery, making it a viable option for AVR.

Background Aortic valve replacement (AVR) has recently been performed at many centers using a minimally invasive approach to reduce postoperative mortality, morbidity, and pain. Most previous reports on minimally invasive AVR (MiAVR) have mainly focused on aortic stenosis, and those exclusively dealing with aortic regurgitation (AR) are few. The purpose of this study was to investigate early surgical results and review our experience with patients with chronic severe AR who underwent AVR via right anterior mini-thoracotomy (RAT). Methods Data were retrospectively collected in this single-center study. Eight patients who underwent RAT AVR between January 2020 and January 2024 were enrolled. Short-term outcomes, including the length of hospital stay, in-hospital mortality, postoperative complications, and echocardiographic data, were analyzed. Results No in-hospital mortalities were observed. Postoperative atrial fibrillation occurred temporarily in three patients (37.5%). However, none required permanent pacemaker implantation or renal replacement therapy. The median values of ventilator time, length of intensive care unit stay, and hospital stay were 17 hours, 34.5 hours, and 9 days, respectively. Preoperative and postoperative measurements of left ventricular ejection fraction were similar. However, the left ventricular end systolic and diastolic diameters significantly decreased postoperatively from 42 mm to 35.5 mm (p=0.018) and 63 mm to 51 mm (p=0.012), respectively. Conclusion MiAVR via RAT is a safe and reproducible procedure with acceptable morbidity and complication rates in patients with chronic severe AR. Despite some limitations such as a narrow surgical field and demanding learning curve, MiAVR is a competent method for AR.

Abstract 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.

Background: The usual surgical technique for heart surgery has been median sternotomy, which provides excellent exposure of all cardiac structures and facilitates the installation of cardiopulmonary bypass and central venous and arterial cannulation. A number of alternative surgical techniques, including the right anterolateral thoracotomy, posterolateral thoracotomy, and partial sternotomy, have been suggested. However, they have been discovered to be less than ideal. We want to share our experience with right anterior mini-thoracotomy versus right axillary mini-thoracotomy for closing an atrial septal defect. Methods: The study was a retrospective cross-sectional study conducted in a hospital. The study comprised patients with atrial septal defect admitted to Green City Hospital in Kathmandu, Nepal. From May 2016 until September 2021. Data was extracted to MS excel sheet, and then transported to the STATA version 17 for analysis. First, we computed descriptive analysis which included calculation of frequency, percentage, mean and median for presentation of socio-demographic variables. Continuous data were tested for normality using Shapiro-Wilk test. Results: A total of 25 patient were included in the study with median age 26 years (20-32). The median aortic cross clamp time was 25 minutes with inter quartile range 25(20-35). The median duration was ranging from 31to 161 minutes. The median time of Ax was 25 minutes and 26 minutes for right anterior mini-thoracotomy and right axillary mini-thoracotomy respectively. The median duration of hospital stay was 4 days with inter quartile range 4(3-4) days. Nearly 36% study participants were associated with abnormal body mass index. (Either under nutrition or over nutritional status). There was a significant association (p=0.024) between right anterior mini-thoracotomy and right axillary mini-thoracotomy for BMI. Conclusions: There were no significant differences between the duration of intensive care unit and hospital stays, axillary time, and complications between the two groups. However, the possibility of less blood loss during surgery and of cosmetic appearance in axillary incision is of special importance. Keywords: Heart surgery; mini-thoracotomy; Nepal; right anterior; right axillary.

Background The aim of this study was to compare the early outcomes of octogenarians undergoing minimally invasive right anterior mini-thoracotomy aortic valve replacement (RAT-AVR) with those undergoing transcatheter aortic valve implantation (TAVI) for aortic valve disease. Methods In this single-center retrospective study, data were collected from octogenarians before and after RAT-AVR and TAVI between January 2021 and July 2022. Short-term outcomes, including the length of hospital stay, in-hospital mortality, all-cause mortality, and other major postoperative complications, were compared and analyzed. Results There were no significant differences in in-hospital mortality, stroke, acute kidney dysfunction requiring renal replacement therapy, length of intensive care unit stay, or length of hospital stay. However, the TAVI group had a higher incidence of permanent pacemaker insertion (10% vs. 0%, p=0.54) and paravalvular leaks (75% vs. 0%, p

Background and aimsTranscatheter tricuspid valve replacement (TTVR) has recently emerged as a novel therapeutic approach for managing severe tricuspid regurgitation (TR). However, surgical tricuspid valve replacement (STVR) continues to be the predominant treatment modality. There are limited comparative data on both procedures. This study aimed to compare clinical and echocardiographic outcomes between patients who underwent mini-thoracotomy transatrial LuX-Valve TTVR and those who underwent STVR.MethodsThis study prospectively collected patients with severe TR who underwent TTVR (n = 29) or isolated STVR (n = 59) at Wuhan Union Hospital from 2019 to 2022. All TTVR patients received the LuX-Valve via a mini-thoracotomy and transatrial approach. The clinical and echocardiographic outcomes were compared at 30-day and one-year follow-ups.ResultsAt baseline, patients with LuX-Valve TTVR had higher surgical risk scores and a greater proportion of right ventricular dysfunction compared with STVR. In the early postoperative period, the STVR group had a greater decrease in right ventricular function. Hospital length of stay (LOS), intensive care unit LOS, total procedure time, and tracheal intubation time were shorter in the TTVR than in the STVR group. The incidence of postoperative paravalvular leaks was higher among patients who underwent TTVR. Compared to the STVR group, the pacemaker implantation rate was lower in the TTVR group. During follow-up, the peak tricuspid valve velocity and mean gradient in the TTVR group were consistently lower than those in the STVR group. There was similar mortality between TTVR and STVR at 30-day and one-year follow-ups.ConclusionsThe mini-thoracotomy transatria LuX-Valve TTVR has a higher incidence of paravalvular leaks and a lower rate of pacemaker implantation than STVR, with similar 30-day and one-year mortality rates. In some respects, mini-thoracotomy transatrial LuX-Valve TTVR may be a feasible and safe treatment option for specific populations, or it could potentially serve as an alternative therapy to supplement conventional STVR. Further follow-up is required to assess differences in long-term clinical outcomes and valve durability.

Objective: The minimally invasive right thoracotomy approach is being increasingly used for aortic valve surgeries. It has several benefits in terms of decreased blood loss and length of hospital stay as compared to conventional sternotomy technique. Selected patients requiring aortic root and ascending aorta surgery can be operated on using a similar approach. In this case series, we share the outcomes of Bentall surgery done through right mini-thoracotomy. Methods: This was a single-center retrospective study of five patients who underwent elective right mini-thoracotomy modified Bentall Procedure. Instruments routinely used in minimally invasive cardiac surgery were used. The outcomes that were evaluated include cross-clamp times, cardiopulmonary bypass (CPB) times, time to extubation, total length of intensive care unit (ICU) and hospital stay, re-exploration rates, and inhospital and 30-day mortality. Results: The mean CPB times and cross-clamp times were 128 and 96 min, respectively. The total circulatory arrest was used in two patients with a mean time of 12 min. The mean time to extubation was 7 h. The mean ICU stay and the total length of hospital stay were 1.5 and 5 days, respectively. No patient required re-exploration for bleeding. We did not have any inhospital or 30-day mortality. Conclusion: The right mini-thoracotomy modified Bentall procedure is reproducible and safe in selected patients with annuloaortic ectasia.

Background In cardiac surgery, minimally invasive surgical procedures have recently been adopted. These innovative procedures have a number of benefits, including less postoperative discomfort, fewer morbidity and mortality, faster recovery, and shorter hospital stays at lower costs. Patients and methods Outcomes of 30 patients who underwent isolated aortic valve replacement, were subjected to a prospective comparative study, were compared. In group A (n = 15) minimally invasive right anterior mini-thoracotomy approach and in group B (n = 15) conventional median sternotomy approach had been used. Results The second group had much higher total morbidity than the first. In group A, blood loss was 335.3 ± 174.5, while in group B, it was 633.3 ± 179.9. In group B, postoperative discomfort was much higher. In both groups, inotropes were determined to be negligible. Group B had a longer total hospital stay (101.7 days) than group A (5.60.6 days). Conclusion In patients undergoing isolated aortic valve replacement, a right anterior mini-thoracotomy lowers postoperative pain, the requirement for blood transfusions, assisted ventilation time, and hospital stay.

Background: Right anterior mini thoracotomy (RAMT) for aortic valve replacement (AVR) is a minimally invasive procedure that avoids sternotomy. Herein, we report the outcomes of patients who underwent redo-cardiac via a RAMT approach for AVR., Methods: This case series reports the clinical outcomes of 14 consecutive redo operations, done in Calgary (Canada) and Gdansk (Poland) between 2020 and 2023. Primary outcomes were 30-day mortality and disabling stroke. Secondary outcomes included surgical times, hemodynamics, permanent pacemaker implantation (PPM), length of ICU and hospital stay, new post-operative atrial fibrillation (POAF), post-operative blood transfusion, incidence of acute respiratory distress syndrome (ARDS), rate of continuous renal replacement therapy (CRRT) and/or dialysis, and chest tube output in the first 12-hours after surgery., Results: Nine patients were male, and the mean age was 64.36 years. There were no deaths, while one patient had a disabling stroke postoperatively. Mean cardiopulmonary bypass and cross clamp-times were 136 min and 90 min, respectively. Three patients needed a PPM, 3 patients needed blood transfusions, and 2 developed new onset POAF. Median lengths of ICU and hospital stays were 2 and 12 days, respectively. There was no incidence of paravalvular leak greater than trace and the average transvalvular mean gradient was 12.23 mmHg., Conclusion: The number of patients requiring redo-AVR is increasing. Redo-sternotomy may not be feasible for many patients. This study suggests that the RAMT approach is a safe alternative to redo-sternotomy for patients that require an AVR., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Fatehi Hassanabad, Fercho, Fatehi Hassanabad, King, Sosniuk, de Waard, Adams, Kent and Karolak.)

AbstractBackgroundMaterial and methodsResultsConclusionsFull sternotomy is the standard approach for combined surgery. Evidence of the minimally invasive approach’s advantages for aortic and mitral valve surgery has been reported. Our aim was to report our experience with minithoracotomy for elective patients presenting with aortic valve stenosis associated with right coronary artery disease.Between January 2016 and August 2021, 17 patients underwent concomitant aortic valve replacement and right coronary artery bypass grafting by right anterior thoracotomy.The mean age was 73.3 years and the mean EuroSCORE 2 was 2.07 ± 1.24. Mean cardiopulmonary bypass and aortic cross-clamp times were 148 ± 29 min and 111 ± 20 min. Thirteen patients (76.0%) had femoral cannulation. Nine saphenous veins (53%), seven right internal thoracic arteries (41%), and one radial artery (6%) were used as a graft. Twelve patients benefited from ultrasonic flow measurements to control the graft. The mean flow rate was 47 ± 39 ml/min, and the mean pulsatility index was 2.4 ± 1.2. The mean postoperative transvalvular gradient was 10.9 ± 4 mmHg. Two patients presented with Grade 1 aortic insufficiency (12%). There was no 30-day mortality.Combined aortic valve replacement and right coronary artery bypass grafting through right anterior thoracotomy is reliable and reproducible in selected patients. [ABSTRACT FROM AUTHOR]

Purpose: We aim to assess the efficacy and safety of left atrial plication (LAP), particularly para-annular plication, using a right mini-thoracotomy approach., Methods: Among 90 mitral valve repair (MVr) procedures performed at our institution between 2016 and 2023, 16 left atrial plication cases for left atrial enlargement (diameter: >50 mm) were assessed; nine cases underwent median sternotomy (conventional) (Group C), and seven cases underwent minimally invasive cardiac surgery (MICS) (Group M). The surgical protocol involved mitral valve repair via a right-sided left atrial approach, incorporating para-annular plication to suture the posterior wall. The mean follow-up duration was 3.3±2.4 years., Results: Mortality within 30 days of surgery or during hospitalization did not occur. Postoperative complications included one case in each group that required reoperation for hemorrhage originating extraneously in the left atrium. Postoperative echocardiographic assessments revealed a comparable reduction in left atrial diameter (C/M: 80.3±7.0/80.7±14.6%; p=0.94), left atrial volume index (55.6±19.3/68.3±34.1%; p=0.36), and aorto-mitral angle (AMA) enlargement (113.8±7.3/107.5±12.2%; p=0.22). The three-year survival rate (88.9%/75.0%; p=0.33) was comparable between groups., Conclusion: The synergistic utilization of left atrial plication with para-annular plication via right mini-thoracotomy can enhance the postoperative outcomes of mitral valve repair., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. The Institutional Review Board of Tottori Prefectural Central Hospital issued approval 2024-05. Prior to the retrospective analysis and reporting of findings, explicit patient consent was obtained. This study was conducted in accordance with the guidelines of the Institutional Review Board of Tottori Prefectural Central Hospital, ensuring adherence to ethical standards (approval number: 2024-05). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Morimoto et al.)

Background and Aims: Transcatheter tricuspid valve replacement (TTVR) has recently emerged as a novel therapeutic approach for managing severe tricuspid regurgitation (TR). However, surgical tricuspid valve replacement (STVR) continues to be the predominant treatment modality. There are limited comparative data on both procedures. This study aimed to compare clinical and echocardiographic outcomes between patients who underwent mini-thoracotomy transatrial LuX-Valve TTVR and those who underwent STVR., Methods: This study prospectively collected patients with severe TR who underwent TTVR ( n  = 29) or isolated STVR ( n  = 59) at Wuhan Union Hospital from 2019 to 2022. All TTVR patients received the LuX-Valve via a mini-thoracotomy and transatrial approach. The clinical and echocardiographic outcomes were compared at 30-day and one-year follow-ups., Results: At baseline, patients with LuX-Valve TTVR had higher surgical risk scores and a greater proportion of right ventricular dysfunction compared with STVR. In the early postoperative period, the STVR group had a greater decrease in right ventricular function. Hospital length of stay (LOS), intensive care unit LOS, total procedure time, and tracheal intubation time were shorter in the TTVR than in the STVR group. The incidence of postoperative paravalvular leaks was higher among patients who underwent TTVR. Compared to the STVR group, the pacemaker implantation rate was lower in the TTVR group. During follow-up, the peak tricuspid valve velocity and mean gradient in the TTVR group were consistently lower than those in the STVR group. There was similar mortality between TTVR and STVR at 30-day and one-year follow-ups., Conclusions: The mini-thoracotomy transatria LuX-Valve TTVR has a higher incidence of paravalvular leaks and a lower rate of pacemaker implantation than STVR, with similar 30-day and one-year mortality rates. In some respects, mini-thoracotomy transatrial LuX-Valve TTVR may be a feasible and safe treatment option for specific populations, or it could potentially serve as an alternative therapy to supplement conventional STVR. Further follow-up is required to assess differences in long-term clinical outcomes and valve durability., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Huang, Sun, Cai, Xie, Zhang, Sun, Li, Fang, He, Zhang, Yang, Wang, Lv, Li and Xie.)

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.

Background: Aortic valve replacement (AVR) has recently been performed at many centers using a minimally invasive approach to reduce postoperative mortality, morbidity, and pain. Most previous reports on minimally invasive AVR (MiAVR) have mainly focused on aortic stenosis, and those exclusively dealing with aortic regurgitation (AR) are few. The purpose of this study was to investigate early surgical results and review our experience with patients with chronic severe AR who underwent AVR via right anterior mini-thoracotomy (RAT)., Methods: Data were retrospectively collected in this single-center study. Eight patients who underwent RAT AVR between January 2020 and January 2024 were enrolled. Short-term outcomes, including the length of hospital stay, in-hospital mortality, postoperative complications, and echocardiographic data, were analyzed., Results: No in-hospital mortalities were observed. Postoperative atrial fibrillation occurred temporarily in three patients (37.5%). However, none required permanent pacemaker implantation or renal replacement therapy. The median values of ventilator time, length of intensive care unit stay, and hospital stay were 17 hours, 34.5 hours, and 9 days, respectively. Preoperative and postoperative measurements of left ventricular ejection fraction were similar. However, the left ventricular end systolic and diastolic diameters significantly decreased postoperatively from 42 mm to 35.5 mm (p=0.018) and 63 mm to 51 mm (p=0.012), respectively., Conclusion: MiAVR via RAT is a safe and reproducible procedure with acceptable morbidity and complication rates in patients with chronic severe AR. Despite some limitations such as a narrow surgical field and demanding learning curve, MiAVR is a competent method for AR.

BackgroundHitherto, no study has evaluated postoperative pain in patients with non-small cell lung cancer (NSCLC) treated with video-assisted mini-thoracotomy (VAMT). In this study, we aimed to assess postoperative pain related to the width of the metal rib spreader in patients who underwent lobectomy using VAMT.MethodsWe retrospectively analysed the data of 94 consecutive patients with NSCLC who underwent lobectomy using VAMT at our institution between March 2019 and May 2022. We divided the patients into groups according to the width ratio of the rib spreader to that of a single intercostal space. Patients with width ratios ≤ 2.5 times were assigned to group A, and those with width ratios > 2.5 times were assigned to group B. Pre-, intra-, and postoperative data were collected and reviewed.ResultsWe successfully performed VAMT in 94 patients with NSCLC. Forty-five patients were in group A, and 49 were in group B. There were no intraoperative mortalities, although one patient, due to respiratory failure, experienced 30-day mortality. There were no significant differences between the two groups in terms of the blood loss volume, operative time, drainage time, postoperative complications, length of hospital stay, or number of lymph node stations explored and retrieved. The drainage volumes (Day 1–Day 3) were higher in group B than in group A (P < 0.05). The postoperative visual analogue scale (VAS) pain scores were significantly lower in Group A than in Group B at 12, 24, and 48 h (P < 0.05), although there was no significant difference in the VAS scores between the two groups at 72 h and 1 week postoperatively (P > 0.05).ConclusionThe smaller the width of the metal rib spreader used in surgery, the less pain experienced by the patient and the faster the recovery. Multicentre, randomised, controlled trials should be conducted in the future.

Objective(s): Surgical Aortic valve replacement (sAVR) is one of the most common valve surgery associated with excellent Results. SAVR can be performed via a full sternotomy (FS) or a minimal invasive surgical (MIS) approach. Many studies compared outcomes of AVR through upper mini-sternotomy (UMS) versus full sternotomy (FS) and others compared right anterior mini-thoracotomy (RAMT) versus full sternotomy (FS). Our aim was to compare early outcomes of AVR by UMS versus RAMT. Methods: The prospective, randomized, comparative multicenter study compared surgical and early outcomes of patients who underwent elective isolated SAVR from January 2021 to January 2024. All consecutive patients had aging group 65-75 years old. Patients are divided into two groups; group [RAMT] and group [UMS]. Selection of RAMT groups according to preoperative chest computed tomography (CT). All patients who had severe aortic stenosis [AS] received a bioprosthetic valve suture bioprosthetic, group [S], or sutureless (Perceval) [SURD]. Results: No differences in both groups about age, preoperative risk factors, and postoperative complications. Operative time was significantly shorter for the SURD group, regardless of approach. However, nowadays a core- knot in the suture valve made almost no time difference. UMS group had less postoperative pain than RAMT group, however with using analgesic and pain killer made differences not obvious. RAMT group had more lung atelectasis, pleural effusion, and limited mobility of the right arm in the first few postoperative days. UMS group could be easily converted to FS if needed. The RAMT had more cosmetic and patient satisfaction. Conclusion: Both approaches are nearly similar in early outcomes and consider the future of total endoscopic and robotic cardiac surgery. [ABSTRACT FROM AUTHOR]

Abstract Background Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation. Methods Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure. Results A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p

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.

Background: With recent advances in cardiac surgery through minimal access, mini-thoracotomy has emerged as an excellent alternative for cardiac myxoma resection. This study analyzed the surgical results of this approach, focusing on postoperative cerebral embolism and tumor recurrence. Methods: We retrospectively reviewed 64 patients (mean age, 56.0±12.1 years; 40 women) who underwent myxoma resection through mini-thoracotomy from October 2008 to July 2020. We conducted femoral cannulation and antegrade cardioplegic arrest in all patients. Patient characteristics and perioperative data, including brain diffusion-weighted magnetic resonance imaging (DWI) findings, were collected. Medium-term echocardiographic follow-up was performed. Results: Thirteen patients (20.3%) had a history of preoperative stroke, and 7 (11.7%) had dyspnea with New York Heart Association functional class III or IV. Sixty-one cases (95.3%) had myxomas in the left atrium. The mean cardiopulmonary bypass and cardiac ischemic times were 69.0±28.6 and 34.1±15.0 minutes, respectively. Sternotomy conversion was not performed in any case, and 50 patients (78.1%) were extubated in the operating room. No early mortality or postoperative clinical stroke occurred. Postoperative DWI was performed in 32 (53%) patients, and 7 (22%) showed silent cerebral embolisms. One patient underwent reoperation for tumor recurrence during the study period; in that patient, a genetic study confirmed the Carney complex. Conclusion: Mini-thoracotomy for cardiac myxoma resection showed acceptable clinical and neurological outcomes. In the medium-term echocardiographic follow-up, reliable resection was proven, with few recurrences. This approach is a promising alternative for cardiac myxoma resection.

Introduction: Atrial myxomas are rare benign tumors; causing obstructive or embolic complications, or even death, depending on their site and size. Therefore, once diagnosed, it should be surgically resected. Atrial myxomas are present about 75% in left atrium (LA) and about 15% in right atrium (RA). Early diagnosis is a challenge because of nonspecific manifestations, and sometimes is asymptomatic and may be discovered accidentally during transthoracic echography (TTE).Minimally invasive cardiac surgery (MICS) has benefits over sternotomy include cosmetically, less pain, and shorter total hospital stay. Materials and Methods:Between January 2011 to December 2020, (50) patients [30 Sternotomy, 20 MICS] underwent surgery for isolated resection of cardiac myxoma. We reported outcomes; cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, conversion to median sternotomy (ST), total hospital stay, complications (stroke, renal failure, respiratory failure, reoperation, and infection), pain, patient¢s satisfaction, recurrence and survival. Follow-up time was from 6-months to 3-years. Results: There is no significant difference in CPB or cross-clamp time between groups. No minimal invasive (MI) cases required conversion to a median ST. Total hospital stay is shorter in the MI group by 2.2 days (p-value = 0.045). No differences present in morbidity or mortality between two groups. Conclusions: Surgical resection of atrial myxoma resection by minimal invasive approach is safe, feasible, and favored over sternotomy

Background: Full median sternotomy has been a standard surgical approach for heart surgery for more than 50 years. Several advantages increasing the use of less invasive approaches to the mitral valve surgery including, cosmetic, blood product use, respiratory, and pain advantages over conventional surgery. Parasternal incision, right mini-thoracotomy and partial sternotomy are described approaches for less invasive cardiac surgery. Objective: Comparing the less invasive approaches via upper partial sternotomy vs right mini-thoracotomy in mitral valve surgery. Methods: Sixty patients, underwent mitral valve surgery in NHI, were enrolled in this study and divided into two equal groups, and randomly assigned into two equal groups: group upper mini-sternotomy (UMS group, n = 30) or group RMT group (n = 30).The preoperative characteristics, operative variables, mortality, and morbidity were analyzed prospectively. Results: No difference were found between the two groups as regards the mortality. However, in Group UMS, blood loss was significantly higher, also cross clamp time and total bypass time were significantly longer. RMT group showed less time on mechanical ventilation, ICU stay and total hospital stay. In Group UMS, two patients (7%) developed deep sternal wound infection, and one patient (3%) suffered unstable sternum and one patient (3%) required permanent pacemaker. Conclusion: Both approaches upper partial sternotomy and right mini thoracotomy are considered a safe alternative for mitral valve replacement and can provide adequate exposure for mitral valve. In Upper partial sternotomy, conventional cardiopulmonary bypass, no specific instruments or endoscope were needed. In right mini thoracotomy, a longer learning curve and special instruments were required, however, it carried better outcome considering patient satisfaction for pain and cosmetic outcome the hospital stay and short return to activity.

Although the conventional methods for endo-cardial pacemaker lead implantation via subclavian or cephalic or axillary vein routes is common, but sometimes due to anatomical variations it is not feasible to access these veins Emergence of newer techniques are useful for lead implantation. This case report focuses on a hybrid approach of combined mini-thoracotomy for endocardial pacemaker lead implantation. This fluoroscopy guided minimal thoracotomy approach with endocardial MRI compatible lead placement had the benefits of simple procedural, minimal hospital stay, low early complication rates and economically viable to the patient.

Background: The right anterior mini-thoracotomy (RAMT) approach has become a popular technique in cardiac surgery and applied in valve surgery. However, there is very limited evidence on the application of RAMT in the Bentall surgery. In the present study, we aimed to evaluate the safety and feasibility of the RAMT approach in Bentall surgery., Methods: A retrospective analysis was performed on 27 patients who underwent Bentall surgery between September 2020 and April 2022 in the First Affiliated Hospital of Xi'an Jiaotong University. Follow-ups were undertaken 1 and 6 months after their operations. The baseline, perioperative, and follow-up results were retrospectively analyzed., Results: A total of 27 male patients aged 48-61 years were included in the study. The operation time ranged from 4.0 to 5.0 hours, with a median of 4.5 hours. The median aortic cross-clamping time was 122 minutes [interquartile range (IQR): 109-145 minutes], and the median cardiopulmonary bypass (CPB) time was 156 minutes (IQR: 143-183 minutes). The median intensive care unit stay was 3 days (IQR: 1.75-4.25 days). The ventilation time ranged from 6.5 to 22.0 hours, with a median of 13.0 hours. The median drainage volume in the first 24 hours was 210 mL. In the following-up data, no deaths or severe complications were observed., Conclusions: The mini-Bentall procedure through an RAMT approach is a feasible and safe approach with few wounds and good clinical results in patients undergoing aortic root replacement., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1757/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Background : Recently, minimally invasive access via right anterolateral mini-thoracotomy (RAMT) has been gaining popularity in cardiac surgery. This approach is also an option for surgeons performing aortic surgery. The aim of this study is to present our surgical method, highlighting the total endoscopic minimally invasive approach via RAMT for replacement of the ascending aorta (AAR) with or without involvement of the aortic root and the aortic valve. Methods : Clinical data of 44 patients from three participating institutions with AAR with or without involvement of the aortic valve or aortic root via RAMT between April 2017 and February 2024 were retrospectively analyzed. According to surgical procedure, patients were divided into two groups, in the AAR and in the Wheat/Bentall group with concomitant valve or root replacement. Operative time, length of ventilation, perioperative outcome, length of intensive care unit (ICU) as well as postoperative hospital stay, and mid- and long-term results were retrospectively analyzed. Results : Mean age was 61.4 ± 10.7 years old with a frequency of male gender of 63.6%. Mean cardiopulmonary bypass (CBP) time and aortic cross-clamping time was 94.9 ± 32.5 min and 63.8 ± 25.9 min, respectively. CPB and aortic clamp time were significantly lower in AAR group. In the first 24 h, the mean drainage volume was 790.3 ± 423.6 mL. Re-thoracotomy due to bleeding was zero. Sternotomy was able to be avoided in all patients. Patients stayed 35.9 ± 23.5 h at ICU and were discharged 7.8 ± 3.0 days following surgery from hospital. Mean ventilation time was 5.8 ± 7.6 h. All patients survived and 30-day mortality was 0.0%. At a median follow-up time of 18.2 months, all patients were alive. The results were similar in both groups. Conclusions : The full endoscopic RAMT approach with 3D visualization is a safe, feasible and promising technique that can be transferred in the field of aortic surgery without compromising surgical quality, postoperative outcomes, or patient safety when performed by an experienced team in a high-volume center.

Objectives: Repairing thoracic aortic aneurysms with endovascular aortic repair (TEVAR) is a safe and minimally invasive method with low morbidity and short postoperative recovery. We developed a novel method to treat descending thoracic aortic aneurysms using a mini-thoracotomy approach in complex patients with difficult access., Methods: A 56-year-old male patient presented with a 3-day history of chest pain. His past surgical history included infrarenal aortic ligation and right axillobifemoral bypass. Thoracic computed tomography angiography (CTA) revealed a saccular aortic aneurysmal dilatation at zone 2 measuring 4.4 × 4 cm. Owing to his surgical history, vascular access through the femoral and iliac arteries or abdominal aorta was impossible. We developed a new technique using a left posterolateral mini-thoracotomy approach to gain vascular access and perform TEVAR, avoiding the need for an open thoracotomy repair., Results and Conclusions: Thoracic CTA performed before discharge revealed complete aneurysmal exclusion and no endoleaks. Postoperative follow-up CTA (6 months and annually thereafter) revealed no aneurysm formation or aortic restenosis. The femoral artery, followed by the iliac artery, is the traditional access route for TEVAR. Left posterolateral mini-thoracotomy may be required as an alternative access in complex patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Abstract Background The case of aortic valve stenosis complicated with lung cancer have compelled cardiovascular surgeons to make challenging. We report the first successful short-term outcomes of one-stage minimally invasive aortic valve replacement and video-assisted thoracoscopic surgery lobectomy through right mini-thoracotomy in a patient with synchronous bicuspid severe aortic valve stenosis which was unsuitable for transcatheter aortic valve implantation and right lung cancer. Case presentation A 76-year-old man with severe aortic valve stenosis was diagnosed with lung cancer of the right upper lobe with stage IA2. Considering the potential risk of tumor metastasis, a one-stage surgical therapy for right lung cancer and type 0 bicuspid aortic valve stenosis was required; however, transcatheter aortic valve implantation was unsuitable due to a bicuspid aortic valve with severe calcification. Therefore, concomitant minimally invasive aortic valve replacement and lobectomy via right mini-thoracotomy were performed. The postoperative course was uneventful. Conclusion Concomitant aortic valve replacement and right lobectomy via right mini-thoracotomy may reduce surgical invasiveness, leading to early recovery. This surgical strategy is a useful option, particularly for patients with aortic valve stenosis complicated with right lung cancer.

Background: The aim of this study was to compare the early outcomes of octogenarians undergoing minimally invasive right anterior mini-thoracotomy aortic valve replacement (RAT-AVR) with those undergoing transcatheter aortic valve implantation (TAVI) for aortic valve disease., Methods: In this single-center retrospective study, data were collected from octogenarians before and after RAT-AVR and TAVI between January 2021 and July 2022. Short-term outcomes, including the length of hospital stay, in-hospital mortality, all-cause mortality, and other major postoperative complications, were compared and analyzed., Results: There were no significant differences in in-hospital mortality, stroke, acute kidney dysfunction requiring renal replacement therapy, length of intensive care unit stay, or length of hospital stay. However, the TAVI group had a higher incidence of permanent pacemaker insertion (10% vs. 0%, p=0.54) and paravalvular leaks (75% vs. 0%, p<0.001)., Conclusion: In the present study on octogenarians, both TAVI and RAT-AVR showed comparable short-term results. Although both procedures were considered safe and effective in the selected group, RAT-AVR had a lower incidence of complete atrioventricular block and paravalvular regurgitation.

OBJECTIVE: Literature is scarce on minimally invasive cardiac surgery in adults with a right vertical infra-axillary thoracotomy approach without using peripheral cannulation. This study aimed to analyze the perioperative, early outcomes of minimally invasive cardiac surgery with direct vision using central aortic-venous cannulation through a right vertical infra-axillary thoracotomy, vs. standard cardiac surgery with median sternotomy. PATIENTS AND METHODS: This retrospective study included the first 100 adult patients who were operated on via right vertical infra-axillary thoracotomy and central aortic and venous cannulation. The control group comprised 100 adult patients who underwent cardiac surgery through a median sternotomy and central aortic and venous cannulation. RESULTS: The thoracotomy group was associated with prolonged aortic cross-clamp time, cardiopulmonary bypass time, and operation time. The amount of postoperative chest tube drainage and blood transfusion was higher in the sternotomy group. No difference was found between the groups in terms of postoperative morbidity and mortality rates. Despite a higher level of pain in the thoracotomy group on the first 3 postoperative days, patient satisfaction was higher in this group. CONCLUSIONS: In a resource-limited setting, minimally invasive cardiac surgery with direct vision using central aortic-venous cannulation through a right vertical infra-axillary thoracotomy may help to establish minimally invasive cardiac surgery with better cosmetic results, and higher patient satisfaction compared to the median sternotomy approach. Outcomes during the learning curve were similar [ABSTRACT FROM AUTHOR]