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Objective: Evidence determining the optimal treatment for cardiac tumors is rare. We report our midterm clinical outcome and patient characteristics of our series undergoing atrial tumor removal through a right lateral minithoracotomy (RLMT)., Methods: From 2015 to 2021, 51 patients underwent RLMT for atrial tumor extirpation. Patients receiving concomitant atrioventricular valvular, cryoablation, and/or patent foramen ovale closure surgery were included. Follow-up was performed using standardized questionnaires (mean: 1,041 ± 666 days). Follow-up involved any tumor recurrence, clinical symptoms, and any recurrent arterial embolization. Survival analysis was successfully achieved in all patients., Results: Successful surgical resection was achieved in all patients. Mean cardiopulmonary bypass and cross-clamping times were 75 ± 36 and 41 ± 22 min, respectively. The most common tumor location was the left atrium ( n = 42, 82.4%). Mean ventilation time was 12.74 ± 17.23 h, intensive care unit stay ranged from 1 to 1.9 days (median: 1 day). Nineteen patients (37.3%) received concomitant surgery. Histopathological analysis showed 38 myxoma (74.5%), 9 papillary fibroelastoma (17.6%), and 4 thrombus (7.8%). Thirty-day mortality was observed in 1 case (2%). One patient (2%) suffered a stroke postoperatively. No patient had a relapse of cardiac tumor. Three patients (9.7%) showed arterial embolization during follow-up. Thirteen follow-up patients (25.5%) were in New York Heart Association class ≤II. Overall survival was 90.2% at 2 years., Conclusions: A minimally invasive approach for benign atrial tumor resection is effective, safe, and reproducible. Of the atrial tumors, 74.5% were myxoma and 82% were located in the left atrium. A low 30-day mortality rate with no manifestation of recurrent intracardiac tumor was observed.

Objective: Venous drainage is often problematic in minimally invasive cardiac surgery (MICS). Here, we describe our experience with a self-expandable stent cannula designed to optimize venous drainage., Methods: The smart canula ® was used in 58 consecutive patients undergoing MICS for mitral valve disease ( n = 40), left atrial myxoma ( n = 3), left ventricular outflow tract obstruction ( n = 1), and aortic valve replacement via a right anterior minithoracotomy ( n = 14) procedures. The venous cannula was placed under transesophageal echocardiography guidance to reach the superior vena cava. Vacuum-assisted venous drainage (between -20 and -35 mm Hg) was used to reach a target flow index of 2.2 L/min/m² at a core temperature of 34 °C using a goal-directed perfusion strategy aimed at a minimum DO 2 of 272 mL/min/m 2 . Cardiopulmonary bypass (CPB) parameters were recorded, and hemolysis-related parameters were analyzed on postoperative days 1 to 7., Results: Mean body surface area and median body mass index were 1.9 ± 0.2 m 2 and 25.2 (23.4, 30.2) kg/m 2 . Mean CPB and median cross-clamping times were 107.7 ± 24.4 min and 64.5 (53, 75.8) min, and median CPB flow during cardioplegic arrest was 4 (3.6, 4.2) L/min (median cardiac index 2.1 [2, 2.2] L/min/m²). Venous drainage was considered sufficient by the surgeon in all cases, and insertion and removal were uncomplicated. Mean SvO 2 during CPB was 80.2% ± 5.5%, and median peak lactate was 10 (8, 14) mg/dL, indicating sufficient perfusion. Mean venous negative drainage pressure during cross-clamping was 27.2 ± 12.3 mm Hg. Platelets dropped by 73.6 ± 37.5 K/µL, lactate dehydrogenase rose by 81.5 (44.3, 140.8) U/L, and leukocytes rose by 3.4 (2.2, 7.2) K/µL on postoperative day 1., Conclusions: The venous smart canula ® allows for optimal venous drainage at low negative drainage pressures, facilitating sufficient perfusion in MICS.

Objective: An accepted landmark to assess feasibility of surgical aortic valve replacement (SAVR) via right anterolateral minithoracotomy (RALT) is the aortic-midpoint to right-sternal-edge distance. We aimed to evaluate single left lung positive-end-expiratory-pressure (SLL-PEEP) ventilation inducing an intraoperative rightward shift of the ascending aorta to improve exposure., Methods: Nineteen patients with aortic stenosis undergoing SAVR via RALT were prospectively analyzed. SLL-PEEP ventilation (20,395 cmH 2 O) via a double-lumen endotracheal tube was applied immediately before transthoracic aortic cross-clamping, thereby inducing rightward shift of the ascending aorta to enhance exposure. We analyzed preoperative computed tomography (CT) reconstructions and intraoperative video recordings. Primary endpoint was extent of rightward shift induced by SLL-PEEP ventilation; secondary endpoints were procedure times and safety events., Results: Mean age was 61 ± 14.8 years and 6 of 19 (31.6%) were female. Mean EuroSCORE II was 0.81% ± 0.04%, STS-PROM was 1.13% ± 0.74%, and mean aortic rightward shift induced by SLL-PEEP ventilation was 10.32 ± 4.14 mm (4 to 17 mm; P = 0.003). Median shift in the group considered suitable for the RALT approach by preoperative CT-scan evaluation was 14.2 mm (IQR 11) and in the less suitable group 11.5 mm (IQR 5). Mean procedure time was 167 ± 28.9 min, CPB time was 105.7 ± 18.4 min, and cross-clamp time was 64.5 ± 13 min. Fifteen patients (79%) received SAVR via RALT with implantation of a bioprosthesis, whereas a rapid-deployment-prosthesis was used in 4 patients (21%). Ten of 19 (53%) patients who were classified as less suitable preoperatively received SAVR via RALT after SLL-PEEP ventilation. No strokes were observed., Conclusions: The SLL-PEEP ventilation maneuver during SAVR via RALT significantly enhances aortic exposure. There were no safety events associated with this maneuver and we were able to demonstrate significant rightward aortic shift in every single patient.

A 58-year-old white male with a history of stroke and deep vein thrombosis presented with an interatrial intraseptal mass. Cardiac-computed tomography demonstrated a thin-walled, well-demarcated cyst in the inferior border of the fossa ovalis protruding into both atria. Removal of the interatrial intraseptal cyst was performed using a minimally invasive three-dimensional endoscopic periareolar approach.

Objective: The term frailty is frequently used during decision-making in transcatheter heart valve procedures. Nevertheless, frailty is still measured by eyeballing rather than by using standardized frailty assessments. In a previous study, we developed a frailty score in a cardiac surgical patient population including patients, who underwent transcatheter aortic valve replacement (TAVR). Here, we present the results from the subsequent validation study focusing on the TAVR cohort., Methods: One hundred thirty patients underwent TAVR. Frailty assessment using the FORECAST (Frailty predicts death One yeaR after Elective CArdiac Surgery Test) was performed. The European System for Cardiac Operative Risk Evaluation and The Society of Thoracic Surgeons (STS) score were assessed as well. Follow-up included assessment of in-hospital and 30-day mortality and morbidity and quality of life using the Short Form-36 questionnaire., Results: Mean age was 83.3 years, and 50% were female. Logistic European System for Cardiac Operative Risk Evaluation was 14.9 ± 8.7%, and STS score was 5.1 ± 3.4%. Mean ± standard deviation FORECAST score was 4.8 ± 3.3 points of 15. In-hospital and 30-day mortality were 6.9% and 7.7%, respectively. Thirty-day Short Form-36 assessment showed a decrease in quality of life in five of ten items after the intervention. Receiver operating characteristic curves showed that the FORECAST is a valid tool to predict in-hospital mortality (area under the receiver operating characteristic curve, 0.73). By combining the FORECAST and the STS score, this effect was even higher (area under the receiver operating characteristic curve, 0.77; P = 0.021). Stratifying the patients according to the FORECAST score showed best survival in the lowest frailty group., Conclusions: The FORECAST is a valid tool to assess frailty in TAVR patients. The FORECAST is easily assessable and can be included in daily clinical routine.

Objective: We tested the hypothesis that simulated three-dimensional prosthesis overlay procedure planning may support valve selection in transcatheter aortic valve implantation (TAVI) procedures., Methods: Preoperative multidimensional computed tomography (MDCT) data sets from 81 consecutive TAVI patients were included in the study. A planning tool was developed, which semiautomatically creates a three-dimensional model of the aortic root from these data. Three-dimensional templates of the commonly used TAVI implants are spatially registered with the patient data and presented as graphic overlay. Fourteen physicians used the tool to perform retrospective planning of TAVI procedures. Results of prosthesis sizing were compared with the prosthesis size used in the actually performed procedure, and the patients were accordingly divided into three groups: those with equal size (concordance with retrospective planning), oversizing (retrospective planning of a smaller prosthesis), and undersizing (retrospective planning of a larger prosthesis)., Results: In the oversizing group, 85% of the patients had new pacemaker implantation. In the undersizing group, in 66%, at least mild paravalvular leakage was observed (greater than grade 1 in one third of the cases). In 46% of the patients in the equal-size group, neither of these complications was observed., Conclusions: Three-dimensional prosthesis overlay in MDCT-derived patient data for patient-specific planning of TAVI procedures is feasible. It may improve valve selection compared with two-dimensional MDCT planning and thus yield better outcomes.

Objective: The aim of this study was to investigate the short-term and midterm outcome of the Engager transcatheter aortic valve implantation (TAVI) system, a transapical self-expanding valve device with anatomic orientation., Methods: Transapical aortic valve implantation with the Engager valve prosthesis was performed in 10 patients. Endpoints were defined according to the Valve Academic Research Consortium recommendations for reporting outcomes of TAVI in clinical trials. Follow-up has been completed after 30 days and 1 year., Results: All patients underwent the implantation procedure successfully. No device-related or delivery system-related complications were observed. One patient died of non-device-related reasons at postoperative day 23 in multiorgan failure. At 30-day follow-up, no more than mild transvalvular and paravalvular aortic regurgitation were seen. After 1 year, no transvalvular regurgitation was observed as assessed by transthoracic echocardiography. None of the patients had more than mild paravalvular leakage. The mean ± SD gradient was 15.3 ± 4.2 mm Hg. New York Heart Association class decreased one degree in mean and sustained until 1-year follow-up. No more patients died until 1-year follow-up., Conclusions: Application of the Engager TAVI system is safe and reliable. Prosthesis deployment in an anatomically correct position was facilitated by the design of the valve prosthesis and successful in all patients. No device-related or delivery system-related complications occurred. Procedural, short-term, and midterm results up to 1 year concerning the aortic valve performance are promising, with stable mean gradients and low rates of even mild regurgitation.

Objective: Obesity is highly prevalent in modern patient populations. Several studies have published conflicting outcomes after minimally invasive surgery with regard to morbidity and mortality. Some instances consider obesity as a relative contraindication for this approach because of inadequate exposure of the surgical field. Our aim was to investigate the outcomes of minimally invasive mitral valve surgery through a right lateral minithoracotomy in patients with a body mass index (BMI) of 30 kg/m2 or greater., Methods: We conducted a retrospective database review between January 1, 2009, and December 31, 2011. Preoperative, intraoperative, postoperative, and follow-up data of 225 consecutive patients were collected., Results: The patients were stratified according to their BMI: 108 had a normal weight with a BMI of lower than 25 kg/m2 (18-24), 90 were overweight with a BMI of 25 to 29 kg/m2, and 27 were obese with a BMI of 30 kg/m2 (30-41) or greater. Statistical analysis showed significantly longer ventilation times in the obese group, whereas all other variables were similar. Survival, major adverse cardiac and cerebrovascular event-free survival, valve competency, and freedom from reoperation were also comparable., Conclusions: Our data suggest that obesity should not deter a surgeon from selecting a minimally invasive approach. Despite longer postoperative ventilation times, a BMI of 30 kg/m2 or greater does not influence short- and medium-term outcome. Obese patients may even benefit from this approach because it avoids the need for sternotomy and therefore reduces the risk for sternal wound infection.