New approach to the mitral valve through the left anterior minithoracotomy for combined valve and coronary surgical procedures.

Objective: We have developed a new technique for accessing the mitral valve through the left anterior minithoracotomy. This approach has been used in patients requiring both mitral valve surgery and coronary artery bypass grafting. Methods: From October 2020 to September 2022, we performed 24 concomitant mitral valve procedures and coronary artery bypass grafting through the left anterior minithoracotomy. The average age of the patients was 65.5 years, and the mean left ventricular ejection fraction was 44.5%. Computed tomography angiography was routinely performed preoperatively. The surgical technique included a left anterior minithoracotomy in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic crossclamping using a transthoracic clamp through the additional port in the left second intercostal space, the administration of cold blood cardioplegia, a right atrial transseptal approach to the mitral valve, and special surgical exposure maneuvers. These maneuvers were designed to displace the heart into the left pleural space by pulling the inferior vena cava tape and the ascending aorta tape to the left. Conventional mitral valve surgical techniques were used. The mitral valve repair or replacement was performed after the distal anastomoses to the right and circumflex coronary system were completed. Subsequently, after the mitral valve procedure, coronary anastomosis to the left anterior descending artery was performed. Results: The mitral valve was effectively visualized, and a planned procedure was successfully completed in all patients. There was no need for conversion to a sternotomy. mitral valve repair was performed in 22 patients (91.7%), and mitral valve replacement was performed in 2 patients (8.3%). Conventional surgical instruments were used in 10 cases (41%), and long-shafted instruments were used in 14 cases (59%). A knot-pusher was required in 9 cases (37.5%). A computed tomography distance from the skin level to the mitral valve posterior annulus of more than 14 cm was identified as a technical difficulty marker, necessitating the use of long-shafted instruments. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomoses was 2.54 ± 0.7 (1; 4). Total operation time was 341 ± 41 (285; 420) minutes, cardiopulmonary bypass time was 231 ± 38 (172; 316) minutes, and the crossclamp time was 127 ± 23 (80; 169) minutes. Patients had a mean intensive care unit stay of 1.87 ± 0.69 (1; 4) days, and their total hospital stay averaged 6.54 ± 1.86 (4; 10) days. There were no reoperations due to bleeding, no occurrences of strokes, and no other major complications. There were no instances of hospital mortality or mortality within 30 days after the procedures. Conclusions: Mitral valve repair or replacement through the left anterior thoracotomy and transseptal approach is a valuable and effective technique that can be used for concomitant procedures performed through a single minithoracotomy incision in selected patients.

New approach for combined aortic valve and coronary procedures through the left anterior minithoracotomy.

OBJECTIVES: We have developed a novel technique for accessing the aortic valve (AoV) through the left anterior minithoracotomy (LAmT). This approach has been used in patients requiring both AoV surgery and coronary artery bypass grafting (CABG). METHODS: From April 2023 to July 2023, we performed 6 concomitant AoV procedures and CABG through the LAmT. The mean age was 71.5 [standard deviation (SD): 5.8; 64; 82] years, and the mean left ventricular ejection fraction was 53% (SD: 12.1; 30; 60). Surgical technique includes LAmT in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic cross-clamping using transthoracic clamp, cold blood cardioplegia, conventional oblique aortotomy and special surgical exposure manoeuvres, aimed to position the ascending aorta and AoV close to the surgical incision. RESULTS: AoV was effectively visualized and the procedure was performed as planned in all 6 patients. No conversion to sternotomy was required. AoV replacement with biological prosthesis was performed in 6 (100%) patients. Conventional surgical instruments were used in all cases. The long-shafted instruments were not required. Knot-pusher was used in 4 (67%)cases. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomosis was 2.0 (SD: 0.6; 1; 3). Total operation time was 371 (SD: 43; 300; 420) min, cardiopulmonary bypass time was 253 (SD: 36; 193; 284) min and cross-clamp time was - 162 (SD: 29; 128; 214) min. intensive care unit stay was-1.5 (SD: 0.55; 1; 2) days, total hospital stay was-7.3 (SD: 1; 6; 9) days. There were no revisions for bleeding, no strokes or other major complications, and no hospital or 30-days mortality. CONCLUSIONS: The simultaneous performance of AoV replacement and multivessel CABG through a single left anterior thoracotomy is technically feasible and can be carried out by experienced surgeons. However, a larger number of cases are required to fully comprehend the potential limitations of this procedure.

Left anterior minithoracotomy as a first-choice approach for isolated coronary artery bypass grafting and selective combined procedures.

OBJECTIVES: Our goal was to describe the technique for and evaluate the results of the isolated coronary artery bypass grafting or combined grafting procedures with mitral valve repair/replacement and/or left ventricle aneurysm repair performed through a single left anterior minithoracotomy. METHODS: Perioperative data of all patients who required isolated or combined coronary grafting from July 2017 to December 2021 were observed. The focus was on 560 patients who underwent isolated or combined multivessel coronary bypass using the "Total Coronary Revascularization via left Anterior Thoracotomy" technique. The main perioperative outcomes were analysed. RESULTS: A left anterior minithoracotomy was used in 521 (97.7%) out of 533 patients who required isolated multivessel surgical coronary revascularization and in 39 (32.5%) out of 120 patients who required combined procedures. In 39 patients, multivessel grafting was combined with 25 mitral valve and 22 left ventricular procedures. Mitral valve repair was performed through the aneurysm (n = 8) or through the interatrial septum (n = 17). Perioperative outcomes in isolated and combined groups were next: aortic cross-clamp time-71.9 (SD: 19.9) and 120 (SD: 25.8) min; cardiopulmonary bypass time-145.7 (SD: 33.5) and 216 (SD: 45.8) min; total operating time-269 (SD: 51.8) and 324 (SD: 52.1) min; intensive care unit stay-2 (2-2) and 2 (2-2) days; total hospital stay-6 (5-7) and 6 (5-7) days; and total 30-day mortality was 0.54 and 0%, respectively. CONCLUSIONS: A left anterior minithoracotomy can be effectively used as a first-choice approach to perform isolated multivessel coronary grafting and can be combined with mitral valve and/or left ventricular repair. Experience with isolated coronary grafting through an anterior minithoracotomy is required to achieve the satisfactory results in combined procedures.

Coronary artery bypass grafting and mitral valve replacement via a left anterior minithoracotomy.

We present a technique for multivessel minimally invasive coronary revascularization combined with mitral valve replacement through a left anterior minithoracotomy. This newly developed technique is unique because it allows us to intervene and repair or replacement the mitral valve with a conventional surgical technique through a limited left anterior approach. The minimally invasive approaches for combined cardiac surgical procedures are being increasingly investigated and are of special interest to cardiac surgeons.

Surgical Maneuver for Ventricular Septal Defect Exposure During Congenital Heart Surgery Through the Right Axillary Transverse Minithoracotomy.

Right axillary transverse minithoracotomy is not conventionally used for ventricular septal defect (VSD) repair because of complicated VSD exposure and the need for a temporary tricuspid valve leaflet detachment to facilitate VSD exposure. Recently, our team developed a new, not previously described surgical maneuver that markedly facilitates perimembranous VSD exposure without any need for tricuspid valve leaflet detachment. The above-mentioned VSD exposure maneuver was used in 21 patients with a median age of 5 months (range, 1.5 to 132 months) and a median body weight of 7 kg (range, 4 to 47 kg). The length of the incision varied from 3 to 4.5 cm over the fourth intercostal space within the anterior and posterior axillary lines. Central cardiopulmonary bypass cannulation and antegrade blood cardioplegia were performed in all patients. Bent/angled instruments were used throughout the procedure to facilitate the surgeon's view. Pericardial sutures and suspension of tricuspid valve chords were used as general exposure maneuvers. A special surgical maneuver aimed at changing the general plane of the ventricular septum was used. It consisted of one intraventricular exposing suture. Sufficient exposure of perimembranous VSD was obtained in all patients and was comparable with what is usually obtained through the median sternotomy. With the use of this new maneuver, all perimembranous VSDs could be safely exposed and repaired with the conventional suturing technique through the right axillary transverse minithoracotomy starting from 2 months of age.

Multivessel Arterial Revascularization via Left Anterior Thoracotomy.

To present the technique and to evaluate the outcomes of the multivessel minimally invasive coronary revascularization through the left anterior thoracotomy. From July 2017 to March 2019 in 229 consecutive patients with isolated multivessel coronary artery disease we performed complete coronary revascularization through the left anterior minithoracotomy (6-8 cm skin incision). In 47 of them we performed multiarterial revascularization using left internal mammary artery and T-shunt with left radial artery or right internal mammary artery. Cardiopulmonary bypass (CPB), Chitwood clamp and blood cardioplegia were used in all patients. Heart strings, encircling tapes and Chitwood clamp were used to reduce the distance from skin to coronary targets. Usual coronary instruments were used. The perioperative outcomes of multiarterial graft strategy group were compared with uniarterial graft strategy group. There were no mortality, no perioperative myocardial infarcts, and no conversion to sternotomy with either graft strategy groups. The mean number of distal anastomoses, CPB time, and total hospital stay were not different between the groups. Aortic cross-clamp time ((83.8 ± 17.4 (45;121) vs 67.8 ± 17.4 (35;146), P < 0.0001) and total operation time (283.5 ± 45 (205;495) vs 254.3 ± 48.6 (175;590), P = 0.0003) were longer in patients with multiarterial revascularization compared to uniarterial revascularization using left internal mammary artery and veins. Multivessel coronary bypass grafting using CPB and cardioplegia can be routinely performed minimally invasively through the left anterior thoracotomy. In selected patients multiarterial revascularization could be done with excellent procedural outcomes.