Roy F. Williams

Isolated and concomitant minimally invasive minithoracotomy aortic valve surgery

Objective: To evaluate whether the outcomes of minimally invasive aortic valve surgery were similar in younger versus older patient groups, as well as whether concomitant minimally invasive aortic valve replacement (AVR) surgeries added significant risks in these populations. Methods: We performed a single‐institution retrospective analysis of 1018 patients undergoing isolated AVR and 378 patients undergoing concomitant AVR procedures over a 6‐year period. All surgeries were via a right minithoracotomy approach, and patients who underwent reoperation were excluded. Results: Mortality was 1.3% in the isolated AVR group and 3.2% in the concomitant AVR group. The incidence of permanent stroke was low in both the isolated and concomitant AVR groups (0.8% and 1.1%, respectively). In both groups, femoral cannulation was associated with equally low stroke rates (0.8% and 0.6%, respectively). When analyzing operative outcomes by age, mortality was similar for the isolated AVR group (age <80 vs ≥80 years, 0.9% vs 2.2%; P = .07) and the concomitant AVR group (<80 vs ≥80 years, 3.2% vs 3.2%; P = .99), whereas transfusion requirements, intensive care unit and hospital lengths of stay, and atrial fibrillation rates were greater in the older subsets of both AVR groups. Conclusions: Minimally invasive right thoracotomy AVR surgery was associated with low stroke and mortality rates in all age groups within 30 days of surgery. Similarly, minithoracotomy concomitant AVR surgery demonstrated excellent results and is deemed feasible in patients with multiple pathologies.

Complications Associated With Femoral Cannulation During Minimally Invasive Cardiac Surgery

BACKGROUND Different types of cannulation techniques are available for minimally invasive cardiac surgery. At our institution, we favor a femoral platform for most minimally invasive cardiac procedures. Here, we review our results utilizing this cannulation approach. METHODS We retrospectively reviewed all minimally invasive valve surgeries that were performed at our institution between January 2009 and January 2015. Operative times, lengths of stay, postoperative complications, and mortality were analyzed. RESULTS We identified 2,645 consecutive patients. The mean age was 69.7 ± 12.77 years, and 1,412 patients (53.4%) were male. Three hundred fifty-eight patients (13.5%) had a history of cerebrovascular accident, 422 (16%) had previous heart surgery, and 276 (10.4%) had a history of peripheral vascular disease. The procedures performed were isolated aortic valve replacements (42.1%), isolated mitral valve operations (40.6%), tricuspid valve repairs (0.57%), double valve surgery (15%), triple valve surgery (0.3%), and ascending aortic aneurysm resection with and without circulatory arrest (5%). Femoral cannulation and central cannulation were utilized in 2,400 patients (90.7%) and 244 patients (9.3%), respectively. The median aortic cross-clamp time and cardiopulmonary bypass time were 81 minutes (interquartile range, 65 to 105) and 113 minutes (interquartile range, 92 to 142), respectively. The median postoperative hospital length of stay was 6 days (interquartile range, 5 to 9). There were 31 cerebrovascular accidents (1.17%), no aortic dissections, two compartment syndromes, two femoral arterial pseudoaneurysms, and 174 (6.65%) groin wound seromas. The overall 30-day mortality was 57 patients (2.15%). CONCLUSIONS Minimally invasive cardiac surgical procedures utilizing femoral cannulation techniques have a low risk of complications.

Mitral valve repair and subvalvular intervention for secondary mitral regurgitation: a systematic review and meta-analysis of randomized controlled and propensity matched studies

BACKGROUND Combining a ring annuloplasty (Ring) with a mitral subvalvular intervention (Ring + subvalvular) in patients with secondary mitral regurgitation (MR) may improve mitral valve (MV) repair durability. However, the outcomes of this strategy compared with a Ring only, have not been clearly defined. METHODS A systematic review and meta-analysis was performed utilizing randomized controlled and propensity matched studies which compared a Ring + subvalvular versus Ring MV repair for the treatment of secondary MR. Risk ratio (RR), weighted mean difference (MD), and the 95% confidence interval (CI) were calculated by the Mantel-Haenszel and inverse-variance methods, for clinical outcomes and echocardiographic measures of follow-up MR, left ventricular (LV) reverse remodeling, and MV apparatus geometry. RESULTS Five studies were identified, with a total of 397 patients. Baseline characteristics were similar between groups, and all patients had moderate to severe secondary MR, with the vast majority in the setting of ischemic cardiomyopathy. A Ring + subvalvular repair consisted of papillary muscle approximation (n=2), papillary muscle relocation (n=2), or secondary chordal cutting (n=1). Follow-up ranged from 10.1 (mean range =0.25-42) to 69 [interquartile range (IQR) =23-82] months. When compared with Ring only at last follow-up, a Ring + subvalvular MV repair was associated with: (I) a smaller MR grade (MD =-0.44, 95% CI -0.69 to -0.19; P=0.0005); (II) a reduced risk of moderate or greater recurrent MR (RR =0.43, 95% CI, 0.27-0.66; P=0.0002); (III) a smaller mean LV end-diastolic diameter (MD =-3.56 mm, 95% CI -5.40 to -1.73; P=0.0001) and a greater ejection fraction (MD =2.64%, 95% CI, 0.13-5.15; P=0.04); and, (IV) an improved MV apparatus geometry. There were no differences in operative mortality, post-operative morbidity, or follow-up survival between surgical approaches. CONCLUSIONS When compared with Ring only, a Ring + subvalvular MV repair is associated with greater LV reverse remodeling and systolic function, less recurrence of moderate or greater MR, and an improved geometry of the MV apparatus at short and mid-term follow-up.

Hybrid repair of aortic arch aneurysms: a comprehensive review

Open total arch replacement (TAR) has become safer with refinements in cerebral protection techniques. The frequent extension of aortic arch aneurysms into the descending thoracic aorta customarily requires a two-staged conventional elephant trunk procedure, carrying relatively high mortality and morbidity risks and high rates of rupture in the interval between the two open surgeries. The technical demands and invasive nature of TAR has therefore precluded many high-risk patients from being surgical candidates for aneurysm repair. As a result, hybrid techniques and approaches to the aortic arch have become common since the adoption of thoracic endovascular aortic repair (TEVAR) and advancement in the commercial grafts that are available. The results of hybrid aortic arch repairs have been encouraging, though with higher rates of re-interventions than TAR and variable reported rates of stroke and spinal cord ischemia. The aim of this publication is to review the current literature on hybrid repair of aortic arch aneurysms.

Staged percutaneous coronary intervention followed by minimally invasive mitral valve surgery versus combined coronary artery bypass graft and mitral valve surgery for two-vessel coronary artery disease and moderate to severe ischemic mitral regurgitation

BACKGROUND The optimal treatment for concomitant two-vessel coronary artery disease (CAD) and moderate to severe ischemic mitral regurgitation (IMR) remains unclear. We compared the results of a staged percutaneous coronary intervention followed by minimally invasive mitral valve surgery (PCI+MIVS) versus combined coronary artery bypass graft and mitral valve surgery (CABG+MVS) in this population. METHODS All consecutive patients with two-vessel CAD and moderate to severe IMR, who underwent PCI+MIVS or CABG+MVS at our institution between February 2009 and April 2014, were retrospectively evaluated. RESULTS There were nine patients identified who underwent PCI+MIVS, and 15 who underwent CABG+MVS, with a mean age of 71±7, and 70±7 years, respectively (P=0.86). The remaining baseline characteristics were similar between both groups, with the exception of a higher prevalence of pre-operative clopidogrel administration (78% versus 27%, P=0.03) and left anterior descending plus left circumflex CAD (78% versus 27%, P=0.03), in those who underwent PCI+MIVS. The PCI+MIVS approach was associated with decreased mean cardiopulmonary bypass (111±41 versus 167±49 min, P=0.01) and aortic cross-clamp (79±32 versus 129±35 min, P=0.003) times, and less median number of intraoperative packed red blood transfusions {2 [interquartile range (IQR), 0-2] versus 3 units (IQR, 1-4), P=0.05}, when compared with CABG+MVS. The rate of mitral valve repair, postoperative complications, 30-day mortality, and 1-year survival did not differ between the surgical approaches. CONCLUSIONS PCI+MIVS for two-vessel CAD and moderate to severe IMR is feasible, and associated with satisfactory outcomes, as compared with CABG+MVS.

Mitral Valve and Subvalvular Repair for Secondary Mitral Regurgitation: Rationale and Clinical Outcomes of the Papillary Muscle Sling

Secondary mitral regurgitation (MR) is a common finding in patients with dilated cardiomyopathy, and it is associated with poor outcomes. It is the result of incomplete systolic closure of the mitral valve (MV) as a consequence of left ventricular dilatation, papillary muscle displacement with impaired systolic shortening, and mitral leaflet tethering. MV surgery may be performed in cases of significant secondary MR despite guideline-directed medical therapy. However, MV repair, which is most commonly performed with an undersized ring annuloplasty, is associated with a 30-60% recurrence of moderate or greater MR at mid-term follow-up. To improve MV repair durability, several adjunctive subvalvular procedures have been proposed, one of which is the addition of papillary muscle approximation utilizing a papillary muscle sling. Recent studies comparing the outcomes of a conventional undersized ring annuloplasty with a MV repair utilizing a papillary muscle sling have reported a significant reduction in recurrent moderate or severe MR, greater left ventricular reverse remodeling, and improved MV apparatus geometry with the addition of the papillary muscle sling. We present a comprehensive review of the pathophysiology of secondary MR, and the rationale and clinical outcomes of MV repair with papillary muscle sling placement for the treatment of secondary MR.

Minimally invasive valve surgery in high-risk patients

The use of minimally, or less invasive, approaches to cardiac valve surgery has increased over the past decade. Because of its less traumatic nature, early studies in lower risk patients demonstrated the approach to be associated with an enhanced recovery, increased patient satisfaction, and good operative outcomes. With time, despite a steep learning curve, surgeons expanded this approach to perform more complex procedures, and include patients with more co-morbidity. The aim of this publication is to review the current literature involving the use of minimally invasive valve surgery (MIVS) in higher-risk patients.

Aortic valve replacement in patients with a left ventricular ejection fraction ≤35% performed via a minimally invasive right thoracotomy

BACKGROUND We evaluated the outcomes of patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35% who underwent minimally invasive aortic valve replacement (AVR), with or without concomitant mitral valve (MV) surgery. METHODS All minimally invasive AVR in patients with a left ventricular ejection fraction ≤35%, performed via a right thoracotomy for aortic stenosis or regurgitation between January 2009 and March 2013, were retrospectively evaluated. The operative characteristics, perioperative outcomes, and 30-day mortality were analyzed. RESULTS There were 75 patients identified: 51 who underwent isolated AVR, and 24 who had combined AVR plus MV surgery for moderate to severe mitral regurgitation. In patients undergoing MV surgery, there were 22 (91.7%) MV repairs [ring annuloplasty =7 (37.5%), transaortic edge-to-edge repair =15 (62.5%)], and 2 (8.3%) replacements. No patient required conversion to sternotomy for inadequate surgical field exposure. The median total mechanical ventilation time and intensive care unit length of stay were 14 (IQR, 8-20) and 42 hours (IQR, 26-93 hours) in the isolated AVR group, and 16.5 hours (IQR, 12-61.5 hours) and 95.5 hours (IQR, 43.5-159 hours) in the AVR plus MV surgery group, respectively. The most common post-operative complication was new-onset atrial fibrillation, which occurred in 15 (29.4%) isolated AVR and 4 (16.7%) AVR plus MV surgery patients. The median hospital length of stay and 30-day mortality was 7 days (IQR, 5-12 days) and 1 (2%) in the isolated AVR group, and 10.5 days (IQR, 5-21 days) and 1 (4.3%) for AVR plus MV surgery. CONCLUSIONS In patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35%, minimally invasive AVR can be performed, with or without concomitant MV surgery, with a low morbidity and mortality.

Percutaneous coronary intervention followed by minimally invasive valve surgery compared with median sternotomy coronary artery bypass graft and valve surgery in patients with prior cardiac surgery

BACKGROUND In patients with prior cardiac surgery requiring re-operative coronary and valve surgery, a hybrid approach of percutaneous coronary intervention followed by minimally invasive valve surgery (PCI + MIVS) may be an alternative to the standard median sternotomy coronary artery bypass and valve surgery (CABG + valve). METHODS The outcomes of patients with prior cardiac surgery, presenting with coronary artery and valvular disease, who underwent PCI + MIVS (N=39) were retrospectively compared with those who underwent CABG + valve (N=28) via a repeat median sternotomy, between February 2009 and April 2014. RESULTS The mean age for the PCI + MIVS versus CABG + valve group was 75±9 and 72±11 years (P=0.54), respectively. The baseline characteristics were similar between groups, with the exception of a greater prevalence of 1-vessel coronary artery disease and clopidogrel or dual antiplatelet therapy at the time of surgery in the PCI + MIVS group, and more 3-vessel coronary artery disease in those undergoing CABG + valve surgery. The PCI + MIVS approach was associated with a decreased aortic cross-clamp (94 vs. 131 minutes, P=0.001) and cardiopulmonary bypass (128 vs. 190 minutes, P<0.001) times, fewer intraoperative packed red blood transfusions (1.3 vs. 3.8 units, P=0.001), shorter intensive care unit length of stay (41 vs. 71 hours, P<0.001), and decreased incidence of prolonged mechanical ventilation (12.8% vs. 35.7%, P=0.03), re-intubation (2.6% vs. 17.9%, P=0.04), when compared with CABG + valve. The thirty-day and two-year mortality were similar, being 7.7% vs. 7.1% (P=0.66), and 12.8% vs. 10.7% (P=0.55), in the PCI + MIVS vs. CABG + valve group, respectively. CONCLUSIONS Hybrid PCI + MIVS in patients with prior cardiac surgery is associated with shorter operative times and intensive care unit length of stay, less need for intraoperative blood cell transfusions, decreased use of mechanical ventilation, and similar short-term and follow-up survival, when compared with CABG + valve surgery via median sternotomy. Randomized trials and multicenter registries are needed to further evaluate this approach.

Outcomes of a hybrid approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement

BACKGROUND In patients requiring coronary revascularization and aortic valve replacement, a combined approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement may be a viable treatment strategy. METHODS The outcomes of 123 consecutive patients with significant coronary artery and aortic valve disease, who underwent percutaneous coronary intervention followed by elective minimally invasive aortic valve replacement between February 2009 and April 2014, were retrospectively evaluated. RESULTS The cohort consisted of 80 males and 43 females, with a mean age of 75.7±8.1 years. Drug-eluting stents were used in 69.9% of the patients, and 64.2% were on dual anti-platelet therapy at the time of aortic valve replacement. Within a median of 39 days (IQR 21-64), 83.7% of the patients underwent primary and 16.3% underwent re-operative minimally invasive aortic valve replacement. Post-operatively, there was 1 (0.8%) cerebrovascular accident, 1 patient (0.8%) required a re-operation due to bleeding, and 2 (1.6%) developed acute kidney injury. Thirty-day mortality occurred in 2 (1.6%) patients. Follow-up was available for all of the patients, and at a mean follow-up period of 14.3±12.5 months, 4 (3.3%) had an acute coronary syndrome, and 1 (0.8%) required a repeat target vessel revascularization. The actuarial survival rate at 1- and 3-year was 92.7% and 89.4%, respectively. CONCLUSIONS In a select group of patients with coronary artery and aortic valve disease, a combined approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement can be safely performed with excellent short-term and midterm outcomes.