Comparison between transcatheter closure and minimally invasive surgery for fossa ovalis atrial septal defect: a single institutional experience.

BACKGROUND: Although, conventional surgical closure of atrial septal defect (ASD) provides excellent results with very low mortality and morbidity, it leaves the scar of incision and postoperative pain. Newer treatment modalities like minimal invasive surgery and percutaneous closure are being increasingly used nowadays where available. AIM: To compare the patient population, success, safety, and efficacy of transcatheter closure of ASD (Group A) with that of minimally invasive surgery (Port Access) (Group B). METHODS: In this retrospective non-randomized study, a record of a total of 640 patients with diagnosis of ASD secundum between May 1997 and October 2006 were reviewed. A total of 470 out of 640 patients were selected for transcatheter closure (Group A) while 170 patients were taken for surgical closure by minimally invasive port access surgery (Group B). The safety and efficacy of two groups was evaluated on the basis of morbidity and mortality, duration of intensive care unit (ICU) stay, total duration of hospital stay, post-procedural complications, residual sequel at time of discharge, and residual flow across the ASD. RESULTS: Success rate in two groups was 97.1% and 99.4%, respectively and had no statistically significant difference. Similarly major complication rate also had no difference in statistical significance (1.8% and 2.9% for Group A and B, respectively). Group B patients had longer hospital stay. A small but significant number of patients were not found suitable for device closure. This number is likely to decrease as experience with technique increases. Port access surgery is currently not possible in small children (femoral artery diameter 35 mm) due to difficulty in cannulation. CONCLUSION: Percutaneous device closure of ASD can be offered as a treatment option in suitable patients. Port access is minimally invasive and an equally safe and effective alternative choice in ASDs with deficient rim in patient with appropriate age and weight.

Cardiac herniation following atrial septal defect closure using port access surgery.

Cardiac herniation, a rare entity, is seen most commonly after traumatic rupture of the pericardium or following pneu-monectomy with partial pericardiactomy. It is rarely seen to occur following closure of a sinus venosus atrial septal defect through the port access technique. A review of the literature in English did not reveal any such case report.

Predictors of operative mortality following primary coronary artery bypass surgery.

BACKGROUND: Although quality assessment of coronary artery patients can be done by 30 days risk-adjusted operative mortality, it is still insufficient to study the outcome after primary coronary artery bypass graft surgery (CABG). In our study, we attempted to determine the factors, which can help predict operative mortality before and after CABG. METHODS: The study population consisted of 1000 prospective patients who underwent primary isolated CABG. Assessment was done by dividing the patients into two groups, i.e. non-survivors ( n= 12) and survivors ( n= 988). Data were analyzed using both univariate and multivariate models. RESULTS: On univariate analysis, recent acute myocardial infarction, intra-aortic balloon counterpulsation (IABC), left ventricular ejection fraction (LVEF) <25%, ventilator-associated pneumonia (VAP), tracheostomy, re-exploration, ventricular arrhythmias, low cardiac output (CO), multiple blood transfusions, post-operative renal dysfunction and longer intensive care unit and hospital stay were found as risk factors for mortality. Multivariate analysis showed that LVEF <25%,VAP, ventricular arrhythmias and low CO independently predicted mortality. Prior knowledge of these risk factors can help not only in predicting the outcome and the risks but also helps to plan the surgical and post-operative course of the patients to improve the morbidity and mortality. CONCLUSION: Our data suggest that operative mortality can be predicted prior to and after surgery considering factors such as LVEF, use of IABC, onset of ventricular arrhythmias and low CO.

Minimally invasive mitral valve surgery.

BACKGROUND: To reduce surgical trauma and the drawbacks associated with sternotomy, we performed robotically controlled, video-assisted mitral valve surgery, using either the port-access or the transthoracic clamp technique. METHODS AND RESULTS: Between September 1997 and September 2000, 221 patients (78 males, 143 females) underwent mitral valve surgery through a small right minithoracotomy using the port-access endovascular cardiopulmonary bypass system. Mitral valve exposure was facilitated with an endoscope attached to a voice-controlled robotic arm (AESOP 3000) allowing stabilization and voice-activated camera positioning. Twenty-six patients underwent mitral valve repair and 195 had valve replacement. In 197 patients, mitral valve surgery was the primary operation, while 24 were redo cases. Skin-to-skin mean operating time was 3.5 +/- 1.2 hours and aortic cross-clamp time was 58 +/- 16 min, mean intensive care unit stay was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. There was no re-exploration for bleeding. There was no late death or re-operation on mean follow-up of 16.4 +/- 12.2 months. Patients showed improvement in their NYHA functional class from 2.6 +/- 0.5 to 1.4 +/- 0.8 postoperatively. Outcomes were compared with those of our previous 220 patients who underwent mitral valve surgery with the median sternotomy approach. CONCLUSIONS: The use of video and robotic assistance in port-access mitral valve surgery not only minimizes the length of the incision, but also gives full visualization of the entire mitral valve apparatus. This approach provides comparable results with the sternotomy approach, as well as marked advantages of reduced intensive care unit stay. ,ower blood transfusion requirement, better cosmesis and earlier hospital discharge.