Techniques and results of direct-access minimally invasive mitral valve surgery: a paradigm for the future.
ABSTRACT Our objective was to determine whether direct-access minimally invasive mitral valve surgery can improve recovery and cost while maintaining the efficacy of conventional surgery.
Minimally invasive mitral valve operations were performed on 106 patients, 58% male, average age 58.1 years, with good ventricular function. Ninety underwent repair of a regurgitant, myxomatous valve, and 16 underwent mitral valvuloplasty for prematurely calcified mitral stenosis. The valve was approached with standard instruments through a 5- to 8-cm right parasternal incision. Eighty-five had open femoral artery-femoral vein cannulation, but this technique has recently been replaced by direct cannulation of the aorta and percutaneous cannulation of the femoral vein for most patients.
There were no operative deaths. The mean mitral regurgitation score (0-4) decreased from 3.7 to 0.7 after the operation. Although ischemic and bypass times were increased, postoperative recovery was accelerated. Ventilatory support time, intensive care unit stay, hospital stay, need for rehabilitation, and return to "normal activities" all improved. Hospital charges, pain medications, and blood transfusions were also reduced. New atrial fibrillation contributed significantly to increased length of stay and charges. There were no deep wound infections. Other complications included re-exploration for bleeding (n = 1), transient ischemic attacks (n = 2), stroke (n = 1), femoral artery injury (n = 5), pseudoaneurysm (n = 2), and antegrade dissection of the ascending aorta (n = 1). Two patients died and 1 required reoperation during a mean follow-up of 8.8 months.
Direct-access minimally invasive mitral valve surgery can accelerate recovery, decrease charges, and decrease pain, while maintaining overall surgical efficacy. It has become our standard approach for isolated primary mitral valve operations.
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ABSTRACT: In the 1990s, the success of 'minimally invasive' laparoscopic operations in other surgical subspecialties sparked an interest in minimally-invasive approaches for cardiac surgery, specifically for mitral valve repair. In 1996 at New York University (NYU) we began our experience with minimally invasive mitral valve repair performed through a small right anterior mini-thoracotomy incision using the Port-Access system in a phase I clinical trial. This was the beginning of our extensive right mini-thoracotomy experience for mitral valve repair at NYU. Currently at our institution the preferred approach for the right mini-thoracotomy mitral valve surgery is through the 3rd or 4th interspace mini-thoracotomy incision. Perfusion is accomplished with direct aortic or femoral cannulation, long femoral venous cannula drainage, and a retrograde cardioplegia catheter placed trans-atrialy in the coronary sinus under TEE guidance. An antegrade cardioplegia and venting needle is placed in the ascending aorta and direct external aortic clamping is achieved with one of several specialized crossclamps. With over four decades of experience, more than 4,000 patients have undergone mitral valve repair at NYU including 1,922 performed through a right mini-thoracotomy. We have reported an overall operative mortality of 1.3%, 8-year freedom from reoperation of 95%, freedom from reoperation or severe recurrent mitral regurgitation of 93%, and freedom from all valve-related complications of 90% for our initial series of 1,071 right mini-thoracotomy mitral valve repair. Based on our extensive experience we believe that mitral valve repair through a right mini-thoracotomy provides a durable and safe alternative to a traditional sternotomy with the benefits of improved cosmesis, reduced post-operative pain, less blood loss with fewer blood transfusions, fewer infections, shorter length of stay, and faster return to activity. It is our standard of care approach for mitral valve surgery.11/2013; 5(Suppl 6):S673-S679. DOI:10.3978/j.issn.2072-1439.2013.10.09
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ABSTRACT: Background Cardiac Surgery has evolved over past 50 years and has become a mature discipline. Minimally Invasive Cardiac Surgery techniques (MICS), warmly welcomed in the developed world, are still to take root in the developing countries. Minimally invasive approach represents a challenge in that it requires a new learning curve and carries apprehension about compromising the surgical results. As for the established surgeon, MICS necessitates a departure from the comfort zone and considerable metamorphosis. Methods Cardiac surgery has been carried at our centre for nearly two decades. Completing first year of our minimally invasive program we did 70 cardiac surgical cases from June 2011 to August 2012. These included 25 Mitral Valve Replacements (MVR), 30 Atrial Septal Defect closures (ASD), 10 Aortic Valve Replacement(AVR) and 5 Coronary Artery Bypass Grafting (CABG). Results There was no peri-op mortality. There were 2 conversions to standard sternotomy both in the early part of our learning curve. One patient developed right lower limb edema related to femoral vein cannulation.10 patients had minor air leak which settled spontaneously. There was one incidence of deep surgical site infection. The mean cross clamp time for ASD closure, MVR and AVR were 26.13 min, 51.10 min and 58.66 min respectively. The median Intensive Care Unit (ICU) stay was 2 days and the median hospital stay was 4 days. Conclusion The Cardiac surgery stage in the developing countries is ripe for the era of MICS. The unique patient population here stands to benefit most from it. Careful patient selection aiming to “tailor the operation to the patient and not the patient to the operation” is the crux of a successful MICS program.Indian Journal of Thoracic and Cardiovascular Surgery 06/2013; 29(2). DOI:10.1007/s12055-013-0213-5
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ABSTRACT: In this note, we obtain the structure of short normal sequences over a finite abelian p-group or a finite abelian group of rank two, thus answering positively a conjecture of Gao and Zhuang for various groups. The results obtained here improve all known results on this conjecture.Journal of Combinatorial Theory Series A 05/2011; 118(4):1519-1524. DOI:10.1016/j.jcta.2010.11.009 · 0.87 Impact Factor