Technique and early outcomes of total thoracoscopic double-valve replacement.

Objective: Reports on aortic and mitral double-valve replacement through total thoracoscopy are scarce, with surgical techniques constantly evolving. We aimed to compare the feasibility and safety between total thoracoscopic double-valve replacement and median sternotomy double-valve replacement. Methods: From November 2021 to March 2023, we performed double-valve replacements in 76 patients using the total thoracoscopic double-valve replacement. The control group comprised 77 patients who underwent median sternotomy double-valve replacement. We analyzed data on baseline characteristics, perioperative events, and early postoperative outcomes. Results: In the total thoracoscopic double-valve replacement group, the cardiopulmonary bypass and aortic crossclamping times were 174.20 ± 38.87 minutes and 120.20 ± 19.54 minutes, respectively; both were significantly longer compared with those in the median sternotomy double-valve replacement group (cardiopulmonary bypass: 123.65 ± 15.33 minutes; aortic crossclamping: 82.86 ± 9.51 minutes, P < .001). The total thoracoscopic double-valve replacement group exhibited an extended operative duration, with a mean of 4.40 ± 0.76 hours, in contrast to 3.21 ± 0.68 hours in the median sternotomy double-valve replacement group (P < .001). Postoperatively, the total thoracoscopic double-valve replacement group demonstrated a significantly shorter mechanical ventilation duration (9.29 ± 3.12 hours) and reduced intensive care unit stay time (24.31 ± 7.29 hours) than the median sternotomy double-valve replacement group (11.49 ± 4.27 hours and 26.76 ± 5.89 hours, respectively; P values of .019 and .040, respectively). Furthermore, the total thoracoscopic double-valve replacement group experienced a shorter postoperative hospitalization time, averaging 6.21 ± 1.58 days, than the median sternotomy double-valve replacement group (8.35 ± 1.07 days, P < .001). The total thoracoscopic double-valve replacement group also exhibited significantly lower chest drainage volume (average 223.91 ± 53.93 mL) than the median sternotomy double-valve replacement group (382.56 ± 61.87 mL, P < .001). In terms of transfusion rates, the total thoracoscopic double-valve replacement group (9.21%) showed a marked reduction compared with the median sternotomy double-valve replacement group (36.36%, P < .001). Both groups had similar major complications. Conclusions: The initial results of the total thoracoscopic double-valve replacement underscore its safety and efficacy. This approach extends the applicability of total thoracoscopic cardiac surgery and warrants deeper exploration.

Left ventricular recovery after total arterial coronary artery bypass grafting versus conventional coronary artery bypass grafting in patients with multivessel coronary artery disease and reduced left ventricular ejection fraction.

BACKGROUND: We compared total arterial revascularization (TAR) versus conventional revascularization (CR) in terms of left ventricular function recovery in patients with multivessel coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF). METHODS: We conducted a retrospective cohort study of 162 consecutive patients with multivessel CAD and reduced LVEF who underwent isolated coronary artery bypass grafting at our institution between January 2013 and July 2022. We assessed left ventricular function by transthoracic echocardiography at admission, before discharge, and at follow-up of 3, 6, and 12 months, using LVEF, global longitudinal peak strain, end-diastolic volume index, and end-systolic volume index. We also evaluated mitral valve regurgitation and graft patency rate at 1 year. RESULTS: The TAR group had a significantly higher increase in LVEF and global longitudinal peak strain, and a significantly lower decrease in end-diastolic volume index and end-systolic volume index than the CR group at 6 and 12 months after surgery. The TAR group also had a significantly lower degree of mitral valve regurgitation than the CR group at all-time points within 12 months after surgery. The TAR group had a significantly higher graft patency rate than the CR group at 12 months. There was no significant difference in hospital mortality or repeat revascularization between the groups. CONCLUSIONS: TAR was associated with better recovery of left ventricular function than CR in patients with multivessel CAD and reduced LVEF. Further studies are needed to confirm these findings in this high-risk population.

Quality of life in young patients with acute type a aortic dissection in China: comparison with Marfan syndrome and non-Marfan syndrome.

BACKGROUND: There is a paucity of Chinese studies evaluating the quality of life (QoL) in young acute type A aortic dissection (AAAD) patients with Marfan syndrome. METHODS: Young adult AAAD patients (younger than 45 years old) underwent surgical treatment at our institution from January 2017 to December 2020 were consecutive enrolled. The hospital survivors completed 1 year of follow up. Patients were divided into two groups according to the presence or absence of Marfan syndrome (MFS). A 1:1 propensity score matching (PSM) with a caliper 0.2 was conducted to balance potential bias in baseline. The follow-up data were analyzed primarily for change in quality of life and anxiety status. RESULTS: After PSM, 32 comparable pairs were matched. The baseline data were comparable and postoperative complications were similar between groups. In terms of SF-36 scale, the role physical, bodily pain, role emotional and mental health subscales were no significantly improved in MFS patients over time. At 1 year after discharged, the subscale of mental health and bodily pain were significantly lower in the MFS group than in the non-MFS group. In terms of HADS assessments, the level of anxiety in MFS patients was significantly higher than in non-MFS patients at 1 year after discharged. CONCLUSIONS: The QoL in young AAAD patients with MFS is lower than those without MFS after surgery. This may be associated with the uncontrollable persistent chronic pain and the uncertainty and concerns for the disease's progression.

Mid-term outcomes of total neointima implantation in surgical repair of acute type A aortic dissection.

Total neointima implantation (patch neointima technique + triple-branched stent graft placement) has been performed in proximal aortic repair for acute type A aortic dissection (ATAAD) for more than 10 years at a center. However, there is no report on the mid-term outcomes with a control group of the surgical procedure. Consequently, the authors aimed to evaluate the safety and efficacy of this technique in this study. Patients who underwent the total neointima implantation were classified as Group A, and those who underwent the conventional aortic root reconstruction with the "sandwich" technique and the total aortic arch replacement were classified as Group B. Furthermore, the authors described the preoperative characteristics, operative data, and patient outcomes. Group A patients experienced a shorter surgery duration, lower volumes of perioperative bleeding, and fewer red blood cell transfusions. The incidence of neurological complications was significantly reduced in Group A. All patients maintained a normal range of proximal aortic sizes after surgery. Kaplan-Meier analysis revealed no significant differences between the patients in the two groups regarding cumulative mortality and the incidence of moderate-to-severe aortic insufficiency. In well-selected patients, total neointima implantation is an alternative procedure for the surgical repair of ATAAD.

Two-incision totally thoracoscopic mitral valve repair combined with radiofrequency atrial fibrillation ablation in rheumatic mitral valve disease: Early results of a case series of 43 consecutive patients.

BACKGROUND: Few studies have reported the outcomes of two-incision total thoracoscopic mitral valve repair (MVr) and concomitant radiofrequency atrial fibrillation ablation (RAFA) in patients with rheumatic mitral valve disease and atrial fibrillation (AF). METHODS: We retrospectively analyzed 43 consecutive patients who underwent MVr and RAFA through two-incision total thoracoscopic technique from October 2018 to June 2022. We collected data on baseline characteristics, perioperative outcomes, and early-term results. RESULTS: The mean age was 55.67 ± 7.64 years and 29 (67.4%) patients had New York Heart Association (NYHA) class III or IV. The mean cardiopulmonary bypass (CPB) time was 115.56 ± 8.53 min and aortic clamping time was 81.42 ± 7.54 min. There were no in-hospital deaths or strokes. The mean preoperative mitral valve orifice area (MVOA) was 0.95 (0.84-1.16) cm2 and increased to 2.56 (2.41-2.87) cm2 at discharge and 2.54 (2.44-2.76) cm2 at 3 months after surgery (P < .001). At discharge, 32 (74.4%) patients were in sinus rhythm, 7 (20.9%) were in junctional or atrial flutter rhythm, and 4 (9.3%) remained in AF. At 6 months, 35 (81.4%) patients were in sinus rhythm, 5 (11.63%) were in junctional or atrial flutter rhythm, and 3 (4.7%) were in AF. CONCLUSIONS: Two-incision total thoracoscopic MVr and RAFA is a safe and effective procedure that can improve the MVOA and promote conversion of AF to sinus rhythm in patients with rheumatic mitral valve disease and AF. Further studies with larger sample size and longer follow-up are needed to confirm the long-term benefits of this approach.

Impact of frailty status on clinical and functional outcomes after concomitant valve replacement and bipolar radiofrequency ablation in patients aged 65 years and older.

BACKGROUND: To evaluate the prognostic value of frailty in older recipients of concomitant valve replacement (VR) and bipolar radiofrequency ablation (BRFA), we examined whether clinical and functional outcomes differed between frail and non-frail groups of older patients referred for concomitant VR and BRFA. METHODS: In a single-center retrospective observational cohort study, we compared the clinical and functional outcomes in frail versus non-frail patients. Frailty was assessed using the 5-item Cardiovascular Health Study (CHS) frailty scale. Patients were divided into two groups, frail and non-frail. Functional outcome was assessed using the internationally validated Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) questionnaire. RESULTS: We enrolled 185 patients aged ≥ 65 years who underwent concomitant VR and BRFA. About 36.2% (n = 67) of the patients were included in the frail group and the remaining patients (n = 118) in the non-frail group. Follow-up was complete with a median duration of 58 months (interquartile range 44-76 months). Significant differences were observed between the two groups with respect to postoperative pulmonary complications (frail vs. non-frail patients, 50.74% vs. 22.9%, respectively, P < .001) and hospital mortality (10.45% vs. 1.69%, respectively, P = .021). The frail group had a higher adjusted risk for all-cause mortality (adjusted HR 4.06; 95% CI 1.33 to 12.38; P = .014) and all-cause hospitalization (adjusted HR 2.24; 95% CI 1.12 to 4.50; P = .023). Frailty was associated with lower overall AFEQT scores at baseline (Estimate, - 0.400; 95% CI - 0.532 to - 0.267; P < .001). Compared to the non-frail group, the frail group continued to have lower overall AFEQT scores with no significant improvement in follow-up at 1 year and 2 years after concomitant VR and BRFA. CONCLUSION: Frail patients had lower baseline AFEQT scores and were more likely to have adverse outcomes from postoperative pulmonary complications, and frailty was also an independent risk factor for long-term all-cause mortality and all-cause rehospitalization. Further studies are needed to assess the impact of frailty.

Early Clinical Outcomes of Thoracoscopic Mitral Valvuloplasty: The First 90 Cases.

BACKGROUND: We reported 90 cases of thoracoscopic mitral valvuloplasty in its early stages and sought to analyze early clinical outcomes. METHODS: Ninety consecutive patients, who underwent thoracoscopic mitral valvuloplasty at our institute between April 2020 and December 2021, were assessed for outcomes. Clinical data, including baseline characteristics, operative data, postoperative data, and early follow-up results, were collected. The early clinical outcomes were used to assess the reliability and efficiency of this technique. RESULTS: No in-hospital death occurred. One patient underwent a median sternotomy for bleeding. Intraoperative transesophageal echocardiography revealed no mitral regurgitation in 82 patients and mitral regurgitation of 0-2 cm2 in six. The remaining two patients with mitral regurgitation >2 cm2 experienced serious systolic anterior motion but underwent successful re-valvuloplasty during a second pump-up. the mean cardiopulmonary bypass time was 177.1±54.8 min and aortic clamping time, 114.0±44.9 min. Each patient received a prosthetic ring (CG Future™), and 64 patients received artificial chordae with an average of 2.7±1.5 (ranging from 1 to 6) pairs. The mean follow up was 8.8±7.0 (range, 1-22 months), while two patients were lost to follow up. Recurrent severe mitral regurgitation was observed in one patient three months after the operation, and mitral valve replacement was performed via median sternotomy. During follow up, one patient died of upper respiratory tract infection, and one suffered from low cardiac output. CONCLUSIONS: Thoracoscopic mitral valvuloplasty is safe and effective and, once surgeons overcome the learning curve, can achieve excellent early clinical outcomes.

Do obese patients benefit from isolated aortic valve replacement through a partial upper sternotomy?

OBJECTIVE: Controversial opinions exist for aortic valve replacement (AVR) through partial upper sternotomy in obese patients. Moreover, this study sought to investigate the potential clinical advantage of partial upper sternotomy aortic valve replacement (mini-AVR) over conventional full sternotomy aortic valve replacement (con-AVR) in obese patients. METHODS: This was a retrospective and observational study. From January 2015 to December 2020, a total of 184 obese [body mass index (BMI) ≥ 30 kg  m2] patients undergoing isolated primary AVR were included: 98 patients underwent conventional full sternotomy, and 86 patients underwent partial upper sternotomy. Propensity score (PS) matching was applied to eliminate the bassline imbalances in the mini-AVR and the con-AVR groups. RESULTS: After one-to-one propensity score matching, two groups of 60 patients were obtained. No in-hospital death occurred in the two groups. In addition, cardiopulmonary bypass time and total operative time were similar across the 2 groups, but the aortic cross-clamp time was significantly shorter in the con-AVR group (P = .0.022). The amount of mediastinal drainage at 48 h after surgery (P = 0.018) and postoperative blood transfusions (P = 0.014) were significantly lower in the mini-AVR group. There was no difference in ventilation time (P = .0.145), but a shorter intensive care unit stay time (P = 0.021) in the mini-AVR group. CONCLUSION: This study demonstrates that aortic valve replacement through a mini-AVR in obese patients is a safe and effective procedure. It outperformed con-AVR in terms of blood loss, blood product transfusion, and ICU stay.

Impact of minimally invasive mitral valve surgery on sexual dysfunction in male patients.

BACKGROUND: Sexual dysfunction after cardiac surgery can seriously affect patients' quality of life, but the impact of cardiac surgery on sexual function has long been neglected. Compared with conventional cardiac surgery, minimally invasive cardiac surgery has the advantages of aesthetic appearance and no disruption of the sternal structure, which can greatly improve the patient's quality of life. However, studies focusing on the effects of minimally invasive mitral valve surgery (MIMVS) on sexual function have not been reported. The objective of this research was to investigate the effects of totally endoscopic mitral valve surgery on health-related quality of life and sexual function in male patients and to provide possible recommendations. METHODS: Patients who underwent median sternotomy or totally endoscopic mitral valve surgery at our institution from January 2019 to December 2020 were selected using an electronic medical record system. Data were collected by questionnaires, including the MOS 36-item short-form health survey and the International Erectile Function Questionnaire. RESULTS: There were 156 male patients who participated in our study. Of these, 112 patients completed all questionnaires. Forty-five patients (40.18%) developed postoperative sexual dysfunction, including 15 patients (29.41%) in the MIMVS group and 30 patients (49.18%) in the conventional MVS group, indicating that the incidence of sexual dysfunction could be reduced by MIMVS and that the MIMVS group scored better on the International Erectile Function Questionnaire (P < 0.05). On the evaluation of health-related quality of life, the MIMVS group scored better than the MVS group on the mental health and bodily pain subscales of the MOS 36-item short-form health survey. In addition, our study showed that postoperative sexual dysfunction was associated with physical functioning and mental health. CONCLUSIONS: In our study, totally endoscopic mitral valve surgery had less adverse effects on sexual function in male patients than conventional mitral valve surgery. In terms of health-related quality of life, totally endoscopic mitral valve surgery was superior to conventional surgery. Patients who opt for totally endoscopic mitral valve surgery may have a more satisfying and healthier sexual life than those who undergo conventional mitral valve surgery.

Extensive repair of acute type A aortic dissection through a partial upper sternotomy and using complete stent-graft replacement of the arch.

BACKGROUND: Partial upper sternotomy (mini-ER) can be used in some adult cardiac surgeries but is seldom performed in the treatment of acute type A aortic dissection (AAAD). This study aimed to assess the feasibility and short-term outcomes of complete stent-graft replacement of the arch with triple-branched stent graft for AAAD through a mini-ER. METHODS: From 2015 to 2018, 254 patients with AAAD underwent complete stent-graft replacement of the arch with a triple-branched stent graft. Replacement was performed with conventional full sternotomy (con-ER) in 142 patients and with mini-ER in the other 112 patients. Using propensity score matching, the clinical data were compared between 100 patients in the mini-ER group and 100 patients in the con-ER group. RESULTS: After propensity score matching, there were no significant between-group differences in aortic cross-clamp time, cardiopulmonary bypass time, or total operative time. The amount of mediastinal drainage and number of red blood cell units were significantly lower in the mini-ER group compared with the con-ER group (P < .001). The intubation time was significantly shorter in the mini-ER group (P < .001). The treatment costs were also lower in the mini-ER group (P < .001). There were no significant between-group differences in 30-day mortality (9% vs 8%; P > .99) or postoperative complications. CONCLUSIONS: This study shows that extensive repair of AAAD through a mini-ER is feasible. It was superior to con-ER in terms of blood loss, postoperative ventilation time, and treatment costs.

Learning Curve from 100 Cases of Totally Thoracoscopic Mitral Valve Replacement.

BACKGROUND: To investigate and analyze the learning curve of totally thoracoscopic mitral valve replacement and provide a quantitative reference for cardiac surgeons to carry out the operation step by step. METHODS: The clinical data were retrospectively analyzed of 100 consecutive patients with totally thoracoscopic mitral valve replacement successively performed by the same surgeon in a single center from May 2019 to June 2020. The learning curve was divided into 2 stages by using cumulative sum analysis, and relevant surgical parameters and perioperative indicators were analyzed. RESULTS: The first stage of the learning curve is the skill acquisition stage, which includes 1 to 40 surgical procedures. The second stage is the proficiency stage, involving 41 to 100 operations. Among the surgical parameters of the patients in the 2 stages, detectable improvements were observed in operative time, cardiopulmonary bypass time, cross-clamp time, and intraoperative injury. After surgery, the amount of drainage, length of hospital stay, blood creatinine levels, and oxygenation index 24 h after surgery were also significantly different between the 2 groups (all P < .05). The age and sex distributions of the patients were balanced, and there was no statistically significant difference in terms of conversion to median sternotomy between the 2 stages (P > .05). CONCLUSIONS: Cumulative sum analysis was used to accurately analyze the learning curve of totally thoracoscopic mitral valve replacement, indicating that 40 cases are needed to master the technique.

A new patch technique for valve-sparing aortic root repair in acute type A aortic dissection.

Valve-sparing aortic root replacement is an attractive option for younger patients with acute type A aortic dissection. This study aimed to design a new patch technique for reconstructing the aortic root and preserving the aortic valve following aortic dissection. Between July 2017 and December 2018, 35 patients underwent valve-sparing aortic root repair using this new patch technique. All participants were in the supine position, transesophageal echocardiography and median sternotomy were routinely performed. After thrombi at the aortic root were removed in acute type A dissection, the luminal aortic intimal dissection was removed until the aortic condition was normalized. In each aortic sinus involved in the dissection, a Dacron-graft patch with the shape corresponding to the defect was sutured to the normal remnant vascular wall or aortic annulus in the aortic sinus using 5-0 Prolene suture to reconstruct the aortic root. A total of 2 patients died, and 1 cerebral infarction, and 3 cases of transient brain dysfunction were recorded. The sinus tube junction and sinus diameter were within the normal ranges when they were reexamined 3 months after surgery. This new patch technique circumvents the redesign of the spatial 3D structure of the aortic valve, is simple to operate, and easy to master. It completely removes the diseased dissection tissue, avoids the use of glue, and is an alternative surgical technique, especially for beginners.

Open Seldinger-guided peripheral femoro-femoral cannulation technique for totally endoscopic cardiac surgery.

BACKGROUND: The cannulation technique used in totally endoscopic cardiac surgery has a significant impact on the overall prognosis of patients. However, there are no large cohort studies to discuss it. Here we report on our research of using open Seldinger-guided technique to establish femoro-femoral cardiopulmonary bypass during totally endoscopic cardiac surgery and evaluate its safety and efficacy. METHODS: The institutional database from 2017 to 2020 was retrospectively reviewed to find cases in which totally endoscopic cardiac surgery was performed. We identified 214 consecutive patients who underwent totally endoscopic cardiac surgery with peripheral femoro-femoral cannulation. All patients underwent femoral artery cannulation. Of these, 201 were cannulated in the femoral vein and 13 were cannulated in the femoral vein combined with internal jugular cannulation. The technique involves surgically exposing the femoral vessel, setting up purse-string over the vessels and then inserting a guidewire into the femoral vessel without a vascular incision, followed by exchange of the guidewire with a cannula. RESULTS: Surgery indications included mitral valve disease in 82.71% (177/214), atrial septal defect in 11.68% (25/214) and tricuspid regurgitation in the remaining 5.61% (12/214). Hospital survival was 98.60% (211/214). There were no cases of stroke and postoperative limb ischaemia. No femoral vessel injuries or wound infections was observed. No late pseudoaneurysms were evident. CONCLUSION: The open Seldinger-guided femoro-femoral cannulation technique is effective and safe. We highly recommend this technique, given its safety, simplicity and speed under direct vision. The limited manipulation of the vessels under direct vision minimizes the risk of local complications.

Hospital outcome of concomitant tricuspid annuloplasty during totally endoscopic mitral valve surgery: a propensity matched study.

BACKGROUND: This study aimed to determine how concomitant tricuspid annuloplasty (TAP) affects the clinical outcomes of patients undergoing totally endoscopic mitral valve surgery. METHODS: This was a single-centre, retrospective study. Between January 2019 and June 2020, 143 patients who underwent totally endoscopic mitral valve surgery in our institution were enrolled. Ninety-two patients who underwent isolated mitral valve surgery were categorized into the minimally invasive mitral valve surgery (MIMVS) group (n=92), and patients who underwent mitral valve surgery with concomitant TAP were categorized into the MIMVS-TAP (n=51) group. Clinical data were collected from all patients, including demographic and perioperative data. We conducted propensity score matching (PSM) by using one-to-one ratio nearest-neighbour matching for baseline demographic data and tricuspid valve-related parameters. Forty patients in each group were matched in this way. Parametric and nonparametric tests were performed for data analysis. RESULTS: Statistically, postoperative mortality within 30 days was not significantly different between the two groups (P=1). No differences were found in serious adverse events, such as stroke or third-degree conduction block, between the two groups after 1:1 PSM (P=1 and P=0.480, respectively). The mean operation time for the MIMVS+TAP group was longer (232.13±36.05 min) than that for the MIMVS group (204.25±28.49 min; P<0.001). The same was true for the cardiopulmonary bypass (CPB) time (169.48±25.96 vs. 153.10±23.00 min; P=0.004) and aortic clamp time (110.80±17.37 vs. 101.00±14.38 min; P=0.005). The duration of the intensive care unit stay and the overall postoperative length of stay were not different between the two groups (P=0.734 and P=0.472, respectively). The postoperative systolic pulmonary artery pressure differed between the two groups [38.00±8.45 (MIMVS); 33.65±7.34 (MIMVS + TAP), P=0.022]. CONCLUSIONS: Our study showed that totally endoscopic mitral valve surgery with concomitant TAP is just as safe and effective as isolated totally endoscopic mitral valve surgery, even with a long surgery duration. Our study also suggested that totally endoscopic mitral valve surgery with concomitant TAP can improve tricuspid function in patients.

Concomitant Tricuspid Annuloplasty in Patients Undergoing Totally Endoscopic Mitral Valve Surgery: A Propensity-Score Matched Analysis.

BACKGROUND: We aimed to evaluate the clinical outcomes of concomitant tricuspid annuloplasty (TAP) in patients undergoing totally endoscopic mitral valve surgery. METHODS: It is a single-center, retrospective study that enrolled a total of 173 patients who underwent mitral valve surgery combined with tricuspid annuloplasty between January 2019 and June 2020 in our institution. Patients who underwent totally endoscopic mitral valve surgery with concomitant tricuspid annuloplasty were categorized into the MIMVS-TAP group (N = 51), and patients who underwent mitral valve surgery with concomitant tricuspid annuloplasty through a median sternotomy were categorized into the MVS-TAP group (N = 122). The data collected included detailed demographic and perioperative data. Each patient in the MIMVS-TAP group was individually matched to a patient in the MVS-TAP group, using the propensity scores, and we obtained a matched sample of 51 patients in each group. Parametric and nonparametric tests were used to analyze outcomes. RESULTS: There were no differences in death rates or related major adverse events between the two groups after propensity score matched analysis. The total operation time was longer in the MIMVS + TAP group versus the MVS+TAP group, as were the mean duration of cardiopulmonary bypass time and the cross-clamp time. The mean duration of intensive care unit stay was longer in the MVS + TAP group compared with that of the MIMVS + TAP group, as was the duration of post-operative hospital stay. CONCLUSIONS: Totally endoscopic mitral valve surgery with concomitant tricuspid annuloplasty can improve a patient's prognosis, with comparable short-term outcomes to those of the open approaches.

Totally endoscopic mitral valve surgery: early experience in 188 patients.

INTRODUCTION: Totally endoscopic technique has been widely used in cardiac surgery, and minimally invasive totally endoscopic mitral valve surgery has been developed as an alternative to median sternotomy for many patients with mitral valve disease. In this study, we describe our experience about a modified minimally invasive totally endoscopic mitral valve surgery and reported the preliminary results of totally endoscopic mitral valve surgery. The aim of this retrospective study is to evaluate the results of totally endoscopic technique in mitral valve surgery. MATERIAL AND METHODS: We retrospectively reviewed the profiles of 188 patients who were treated for mitral valve disease by modified totally endoscopic mitral valve surgery at our institution between January 2019 and December 2020. The procedure was performed under endoscopic right minithoracotomy and with femoro-femoral cannulation using the single two-stage venous cannula. RESULTS: A total of 188 patients underwent total endoscopic mitral valve surgery. Fifty-six patients had concomitant tricuspid valvuloplasty, 11 patients underwent concomitant ablation of atrial fibrillation and atrial septal defect repair was performed in three patients. Only one patient postoperatively died of multi-organ failure. Two patients were converted to median sternotomy. Except for one patient underwent operation to stop the bleeding from the incision site, no other serious complications nor reintervention occurred during the follow-up period. CONCLUSIONS: The modified totally endoscopic mitral valve surgery performed at our institution is technically feasible and safe with the same efficacy as reported studies.

Peripheral vascular complications following totally endoscopic cardiac surgery.

BACKGROUND: Clinical application of minimally invasive cardiac surgery has increased annually. Cardiopulmonary bypass is established by peripheral cannulation during minimally invasive cardiac surgery. The methodology of peripheral cannulation has unique characteristics, which have associated risks and complications. Few studies have been conducted on this topic. In this study, we focused on complications of peripheral cannulation in totally endoscopic cardiac surgery. METHODS: Patients who underwent totally endoscopic cardiac surgery with cardiopulmonary bypass established by peripheral cannulation at our institution between January 2019 and June 2020 were reviewed. Specific cannulation strategies and related cannulation complications were noted. RESULTS: One hundred forty-eight patients underwent totally endoscopic cardiac surgery. One hundred forty-eight cannulations were performed in the femoral artery and vein, and eleven were performed in the internal jugular vein (combined with the femoral vein). The median size of the femoral artery cannula was 22Fr, and that of the venous canula was 24Fr. One patient died of retroperitoneal haematoma due to femoral artery injury. Three patients had postoperative lower limb oedema. One patient had a postoperative diagnosis of femoral vein thrombosis. CONCLUSIONS: Different from cannulation in patients with aortic dissection and aneurysms, femoral artery cannulation is safe in totally endoscopic cardiac surgery. Venous cannulation is characterized by a large-bore venous cannula and a short period of use. There are few reports about complications of venous cannulation. The main complication in this study was mechanical injury, and the key to preventing this injury is meticulous manipulation during surgery.

Patch Neointima Technique in Acute Type A Aortic Dissection: Midterm Results of 147 Cases.

BACKGROUND: The patch neointima technique is a modified valve-sparing aortic root repair surgery for acute type A aortic dissection and the short-term outcomes are satisfactory. The midterm outcomes have not been reported. METHODS: From January 2009 to December 2012, 147 patients underwent valve-sparing aortic root repair with the patch neointima technique for type A aortic dissection in our center. The midterm outcomes of the patients were evaluated by echocardiography and aortic computed tomography angiography. RESULTS: Of 147 patients, 32 patients (21.8%) underwent proximal arch repair, and 115 patients (78.2%) underwent proximal arch repair combined with triple-branched stent graft implantation. The perioperative mortality was 5.4%. Preoperative aortic insufficiency (AI) was observed in 94 patients (63.9%); 131 patients (89.1%) left the operating room with 0 AI; the remaining 16 patients (10.9%) had trace or less than 1+ AI. A total of 128 patients (87.1%) completed 7-year follow-up. The mean follow-up time was 5.7 ± 1.2 years. As many as 82% of patients (105) were 0 AI and 15.6% of patients (20) were 0.5+ trace or less than 1+ AI. No reoperation was performed for the aortic root. The diameters of sinotubular junction and sinus were reduced to the normal range (28.3 ± 4.2 mm and 30.5 ± 3.6 mm, respectively) and remained stable (28.9 ± 5.6 mm, P = .300, and 30.8 ± 4.2 mm, P = .540, respectively) during 7 years of follow-up. CONCLUSIONS: Valve-sparing aortic root repair with patch neointima technique was associated with stable function of the aortic valves and no expansion of the aortic root in the midterm.

Combined femoral and axillary perfusion strategy for Stanford type a aortic dissection repair.

BACKGROUND: The optimal cannulation strategy in surgery for Stanford type A aortic dissection is critical to patient survival but remains controversial. Different cannulation strategies have their own advantages and drawbacks during cardiopulmonary bypass. Our centre used a combined femoral and axillary perfusion strategy for the surgical treatment of type A aortic dissection. The purpose of this study was to review and clarify the clinical outcome of femoral artery cannulation combined with axillary artery cannulation for the treatment of Stanford type A aortic dissection. METHODS: We performed a retrospective study that included 327 patients who were surgically treated for type A aortic dissection in our institution from January 2017 to June 2019. Femoral and axillary artery cannulation was used to establish cardiopulmonary bypass in patients with type A aortic dissection. The demographic data, surgical data, and clinical results of the patients were calculated. RESULTS: Femoral artery combined with axillary artery cannulation was technically successful in 327 patients. The cardiopulmonary bypass time was 141.60 ± 34.89 min, and the selective antegrade cerebral perfusion time was 14.94 ± 2.76 min. The early mortality rate was 3.06%. The incidence of permanent neurologic dysfunction was 0.92%. Sixteen patients had postoperative renal insufficiency, and five patients had liver failure. CONCLUSION: Femoral artery combined with axillary artery cannulation for type A aortic dissection can significantly improve the prognosis of patients, especially in terms of cerebral protection, and can reduce the occurrence of adverse malperfusion syndrome and neurological complications.

The use of the Scar Cosmesis Assessment and rating scale to evaluate the cosmetic outcomes of totally thoracoscopic cardiac surgery.

BACKGROUND: Conventional median sternotomy is widely used in cardiac surgery, while thoracoscopic cardiac surgery, which is considered to have aesthetic advantages, is being performed increasingly more often in China because patients' requests for minimally invasive procedures yielding aesthetically pleasing results have significantly increased. Few studies have been conducted to assess surgical scars after cardiac surgery. Compared to the median sternotomy approach, multiple-incision totally thoracoscopic cardiac surgery requires smaller but numerous and scattered incisions. In addition to two working ports on the upper and lower margins of the right breast, an inguinal incision and an axillary incision are made. Therefore, does totally thoracoscopic cardiac surgery truly have aesthetic advantages? This study has the following objectives: (a) to compare median sternotomy cardiac surgery and total thoracoscopic cardiac surgery in terms of the long-term cosmetic outcomes of post-operative scars and (b) to evaluate the effectiveness of the Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale in the assessment of surgical scars after cardiac surgery. METHODS: Consecutive patients who visited our institution from January 2019 to May 2019 for cardiac surgery via median sternotomy or the totally thoracoscopic approach and followed up for at least one year were included. Inter-rater reliability, internal consistency and convergent validity were evaluated for the Scar Cosmesis Assessment and Rating scale and the numeric rating scale. Clinical characteristics and the scores of the two scales were compared between the two groups using Student's t test or the Mann-Whitney U test. RESULTS: Thirty-one patients underwent cardiac surgery via the totally thoracoscopic approach, and 42 patients underwent cardiac surgery via the median sternotomy approach. No significant differences were found in the demographic or clinical data between the two groups. The validity and reliability of the two scales were satisfactory. For the Scar Cosmesis Assessment and Rating scale, the median sternotomy group scored statistically significantly higher than did the totally thoracoscopic group on the "overall impression" and "patient question" subscales (P < 0.05). The overall scores of the Scar Cosmesis Assessment and Rating scale and numeric rating scale were statistically significantly different (P < 0.05). CONCLUSIONS: The Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale is an effective tool for the assessment of scar aesthetics after cardiac surgery. Surgical scars of totally thoracoscopic cardiac surgery can yield desirable cosmetic outcomes in Chinese individuals, especially in susceptible individuals with a high risk of keloid and hypertrophic scars. Patients with appropriate indications can undergo cardiac surgery with the totally thoracoscopic approach and exhibit a satisfactory scar appearance.