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Innovations in Minimally Invasive Cardiac Surgery

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A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Surgery".

Deadline for manuscript submissions: closed (20 April 2023) | Viewed by 12650

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Special Issue Editors

Prof. Dr. Aron-Frederik Popov

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Guest Editor

Department of Cardiothoracic, Transplantation and Vascular Surgery, Medical High School Hannover, Hannover, Germany
Interests: heart failure surgery; heart and lung transplantation; ECLS; MCS (short and long term); minimally invasive cardiac surgery; reconstructive valve surgery; aortic surgery; bypass surgery; innovations in surgery
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Alexander Weymann

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Guest Editor

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
Interests: ventricular assist devices; artificial hearts; heart failure surgery; redo cardiac surgery; heart and lung transplantation; extra corporeal life support; aortic and mitral valve surgery; minimally invasive surgery; critical care

Special Issue Information

Dear Colleagues,

Throughout the past decades, Minimally Invasive Cardiac Surgery (MICS) underwent a substantial transformation, leading to its advancement. Following its introduction in the cardiac surgical field, MICS was welcomed with major enthusiasm and eagerness for its application. Indeed, numerous benefits have been attributed to MICS, including a reduction in pain, a decrease in the length of hospital stay, and less need for blood products. Nevertheless, concerns were raised regarding the potential for major complications and extended operative times occurring in complex operative cases.

These concerns in relation to patient safety were able to be partially addressed through technological innovation covering surgical instrumentation, robotic technology, and perfusion techniques, thus facilitating the transition from open-heart surgery to MICS. While MICS has been illustrated to be a safe and effective treatment, its efficacy is still a matter of discussion when compared to standard sternotomy cardiac surgery. In fact, most of the early published literature covering MICS consisted of surgical techniques or small case series reports. Nonetheless, late reports analyzing long-term outcome data of MICS illustrated its safety, durability, and in most cases its feasibility when compared to open-heart surgery.

In the following special issue, the technological progress made in the field of MICS is considered and updates are offered on all the main areas of cardiac surgery covering MICS, with particular attention towards both its current state and future direction.

Prof. Dr. Aron-Frederik Popov
Prof. Dr. Alexander Weymann
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Medicina is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

endoscopic heart surgery
reconstructive valve surgery
minimally invasive cardiac surgery
MIDCAB
multivessel MIS surgery
MIC ablation surgery
robotic cardiac surgery
aortic surgery

Published Papers (6 papers)

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Research

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11 pages, 2679 KiB

Open AccessArticle

Right-Sided Minimally Invasive Direct Coronary Artery Bypass: Clinical Experience and Perspectives

by Florian Hecker, Mascha von Zeppelin, Arnaud Van Linden, Jan-Erik Scholtz, Stephan Fichtlscherer, Jan Hlavicka, Thomas Walther and Tomas Holubec

Medicina 2023, 59(5), 907; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina59050907 - 09 May 2023

Cited by 1 | Viewed by 1422

Abstract

Objective: Minimally invasive direct coronary artery bypass grafting (MIDCAB) using the left internal thoracic artery to the left descending artery is a clinical routine in the treatment of coronary artery disease. Far less is known on right-sided MIDCAB (r-MIDCAB) using the right internal thoracic artery (RITA) to the right coronary artery (RCA). We aimed to present our experience in patients with complex coronary artery disease who underwent r-MIDCAB. Materials and Methods: Between October 2019 and January 2023, 11 patients received r-MIDCAB using RITA to RCA bypass in a minimally invasive technique via right anterior minithoracotomy without using a cardiopulmonary bypass. Underlying coronary disease was complex right coronary artery stenosis (n = 7) and anomalous right coronary artery (ARCA; n = 4). All procedure-related and outcome data were evaluated prospectively. Results: Successful minimally invasive revascularization was achieved in all patients (n = 11). There were no conversions to sternotomy and no re-explorations for bleeding. Furthermore, no myocardial infarction, no strokes, and, most importantly, no deaths were observed. During the follow-up period (median 24 months), all patients were alive and 90% were completely angina free. Two patients received a repeated revascularization after surgery but independently from the RITA-RCA bypass, which was fully competent in both patients. Conclusion: Right-sided MIDCAB can be performed safely and effectively in patients with expected technically challenging percutaneous coronary intervention of the RCA and in patients with ARCA. Mid-term results showed high freedom from angina in nearly all patients. Further studies with larger patient cohorts and more evidence are needed to provide the best revascularization strategy for patients suffering from isolated complex RCA stenosis and ARCA. Full article

(This article belongs to the Special Issue Innovations in Minimally Invasive Cardiac Surgery)

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14 pages, 1311 KiB

Open AccessArticle

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Aortic Valve Surgery

by Manuel Wilbring, Konstantin Alexiou, Torsten Schmidt, Asen Petrov, Ali Taghizadeh-Waghefi, Efstratios Charitos, Klaus Matschke, Sebastian Arzt and Utz Kappert

Medicina 2023, 59(1), 160; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina59010160 - 13 Jan 2023

Cited by 7 | Viewed by 1626

Abstract

Background and Objectives: Transaxillary access is one of the latest innovations for minimally invasive aortic valve replacement (MICS-AVR). This study compares clinical performance in a large transaxillary MICS-AVR group to a propensity-matched sternotomy control group. Materials and Methods: This study enrolled 908 patients undergoing isolated AVR with a mean age of 69.4 ± 18.0 years, logistic EuroSCORE of 4.0 ± 3.9%, and body mass index (BMI) of 27.3 ± 6.1 kg/m². The treatment group comprised 454 consecutive transaxillary MICS-AVR patients. The control group was 1:1 propensity-matched out of 3115 consecutive sternotomy aortic valve surgeries. Endocarditis, redo, and combined procedures were excluded. The multivariate matching model included age, left ventricular ejection fraction, logistic EuroSCORE, pulmonary hypertension, coronary artery disease, chronic lung disease, and BMI. Results: Propensity-matching was successful with subsequent comparable clinical baselines in both groups. MICS-AVR had longer skin-to-skin time (120.0 ± 31.5 min vs. 114.2 ± 28.7 min; p < 0.001) and more frequent bleeding requiring chest reopening (5.0% vs. 2.4%; p < 0.010), but significantly less packed red blood cell transfusions (0.57 ± 1.6 vs. 0.82 ± 1.6; p = 0.040). In addition, MICS-AVR patients had fewer access site wound abnormalities (1.5% vs. 3.7%; p = 0.038), shorter intensive care unit stays (p < 0.001), shorter ventilation times (p < 0.001), and shorter hospital stays (7.0 ± 5.1 days vs. 11.1 ± 6.5; p < 0.001). No significant differences were observed in stroke > Rankin 2 (0.9% vs. 1.1%; p = 0.791), renal replacement therapy (1.5% vs. 2.4%; p = 0.4762), and hospital mortality (0.9% vs. 1.5%; p = 0.546). Conclusions: Transaxillary MICS-AVR is at least as safe as AVR by sternotomy and can be performed in the same time frame. Its advantages are fewer transfusions and quicker postoperative recovery with a significantly shorter hospital stay. The cosmetic result and unrestricted physical abilities due to the untouched sternum and ribs are unique advantages of transaxillary access. Full article

(This article belongs to the Special Issue Innovations in Minimally Invasive Cardiac Surgery)

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9 pages, 1220 KiB

Open AccessArticle

Treatment of Complex Two-Vessel Coronary Heart Disease with Single Left Internal Mammary Artery as T-Graft with Itself—A Retrospective Double Center Analysis of Short-Term Outcomes

by Christian Jörg Rustenbach, Ilija Djordjevic, Kaveh Eghbalzadeh, Hardy Baumbach, Stefanie Wendt, Medhat Radwan, Spiro Lukas Marinos, Migdat Mustafi, Mario Lescan, Rafal Berger, Christoph Salewski, Rodrigo Sandoval Boburg, Volker Steger, Attila Nemeth, Stefan Reichert, Thorsten Wahlers and Christian Schlensak

Medicina 2022, 58(10), 1415; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58101415 - 09 Oct 2022

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Abstract

Background and Objectives: The strategy of revascularization may be constrained in patients with insufficient bypass grafts and with increased risk of wound healing disorders. Among those with complex left-sided double-vessel disease in whom a percutaneous coronary intervention (PCI), as well as the surgical procedure of minimally invasive coronary artery bypass grafting via left minithoracotomy (MICS CABG), is not a treatment option, CABG using the left internal mammary artery as a T-graft with itself may be an effective treatment strategy. Materials and Methods: We reviewed the data from patients treated in Cologne and Tuebingen from 2019 to 2022. We included 40 patients who received left internal mammary artery (LIMA) grafting, and additional T-graft with the LIMA itself. The objective was focused on intraoperative and short-term outcomes. Results: A total of 40 patients were treated with the LIMA-LIMA T-graft procedure with a Fowler score calculated at 20.1 ± 3.0. A total of 37.5% of all patients had lacking venous graft material due to prior vein stripping, and 21 patients presented severe vein varicosis. An overall of 2.6 ± 0.5 distal anastomoses (target vessels were left anterior descending, diagonal, intermediate branch, and/or left marginal ramus) were performed, partly sequentially. Mean flow of LIMA-Left anterior descending (LAD) anastomosis was 59.31 ± 11.04 mL/min with a mean PI of 1.21 ± 0.18. Mean flow of subsequent T-Graft accounted for 51.31 ± 3.81 mL/min with a mean PI of 1.39 ± 0.47. Median hospital stay was 6.2 (5.0; 7.5) days. No incidence of postoperative wound healing disorders was observed, and all patients were discharged. There was one 30-day readmission with a diagnosis of pericardial effusion (2.5%). There was no 30-day mortality within the cohort. Conclusions: Patients requiring surgical myocardial revascularization due to complex two-vessel coronary artery disease (CAD) can be easily managed with LIMA alone, despite an elevated Fowler score and a promising outcome. A prospective study needs to be conducted, as well as longer term surveillance, to substantiate and benchmark the long-term results, as well as the patency rates. Full article

(This article belongs to the Special Issue Innovations in Minimally Invasive Cardiac Surgery)

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12 pages, 1628 KiB

Open AccessArticle

Upper Hemi-Sternotomy Provides Benefit for Patients with Isolated or Combined Mitral Valve Surgery

by Cenk Ulvi Oezpeker, Fabian Barbieri, Daniel Hoefer, Nikolaos Bonaros, Michael Grimm and Ludwig Mueller

Medicina 2022, 58(2), 142; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58020142 - 18 Jan 2022

Cited by 1 | Viewed by 1782

Abstract

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. Full article

(This article belongs to the Special Issue Innovations in Minimally Invasive Cardiac Surgery)

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14 pages, 2014 KiB

Open AccessArticle

Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach

by Erik Bagaev, Ahmad Ali, Shekhar Saha, Sebastian Sadoni, Martin Orban, Michael Naebauer, Julinda Mehilli, Steffen Massberg, Andreas Oberbach and Christian Hagl

Medicina 2022, 58(1), 93; https://doi.org/10.3390/medicina58010093 - 07 Jan 2022

Cited by 3 | Viewed by 1953

Abstract

Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 ± 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 ± 31 min and cardiopulmonary bypass was 137 ± 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This “off label” implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC. Full article

(This article belongs to the Special Issue Innovations in Minimally Invasive Cardiac Surgery)

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Review

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6 pages, 753 KiB

Open AccessReview

Expanding the Minimally Invasive Approach towards the Ascending Aorta—A Practical Overview of the Currently Available Techniques

by Florian Helms, Bastian Schmack, Alexander Weymann, Jasmin Sarah Hanke, Ruslan Natanov, Andreas Martens, Arjang Ruhparwar and Aron-Frederik Popov

Medicina 2023, 59(9), 1618; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina59091618 - 07 Sep 2023

Viewed by 1723

Abstract

Minimally invasive techniques have gained immense importance in cardiovascular surgery. While minimal access strategies for coronary and mitral valve surgery are already widely accepted and often used as standard approaches, the application of minimally invasive techniques is currently expanded towards more complex operations of the ascending aorta as well. In this new and developing field, various techniques have been established and reported ranging from upper hemisternotomy approaches, which allow even extensive operations of the ascending aorta to be performed through a minimally invasive access to sternal sparing thoracotomy strategies, which completely avoid sternal trauma during ascending aorta replacements. All of these techniques place high demands on patient selection, preoperative planning, and practical surgical implementation. Application of these strategies is currently limited to high-volume centers and highly experienced surgeons. This narrative review gives an overview of the currently available techniques with a special focus on the practical execution as well as the advantages and disadvantages of the currently available techniques. The first results demonstrate the practicability and safety of minimally invasive techniques for replacement of the ascending aorta in a well-selected patient population. With success and complication rates comparable to classic full sternotomy, the proof of concept for minimally invasive replacement of the ascending aorta is now achieved. Full article

(This article belongs to the Special Issue Innovations in Minimally Invasive Cardiac Surgery)

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