Does A Single Endoscopic Access For Aortic Valve Replacement Preclude Concomitant Procedures?
tommaso hinna danesi, Giovanni Domenico Cresce, Massimo Sella, Loris Salvador.
Ospedale San Bortolo Vicenza, Vicenza, Italy.
BACKGROUND: To evaluate whether the single endoscopic surgical access for aortic valve replacement is feasible in concomitant mitral,tricuspid or complex procedures. METHODS: We performed a single-institution retrospective analysis of 148 patients (mean age 69.1 ± 11.3 years; 77 males, mean EuroScre II 1.51 ± 1.39) undergoing minimally invasive aortic valve replacement (AVR) over a 5-years period. All surgeries were via a totally endoscopic approach. The surgical access was a single 2.5 cm to 3.5 cm working port in the second right intercostal space without any rib spread or resection; three additional 5 mm mini-ports were made for the introduction of a 30 degree thoracoscope, the ventline and the Chitwood clamp. Cardiopulmonary bypass (CPB) was instituted through a peripheral cannulation.RESULTS: All Patients underwent endoscopic AVR. Over 148 Patients 30 (20.2%) received an additional procedure. Associated procedures were: interventricular septum miectomy in 8 patients, mitral valve repair in 8, mitral valve replacement in 6; ascending aorta plication and replacement in 4 and 2 patient respectively. A triple valve surgery was performed in 2 patients.Mean CPB time was 128 ± 30.4 and 62.3±44.6 minutes in isolated AVR and combined surgery respectively (p<0.05). Aortic crossclamp time in isolated AVR was 88.8 ± 23.2 and 121.5±37.2 minutes in combined surgery (p<0.05).One conversion to sternotomy due to intraoperative coronary artery obstruction requiring CABG was needed. Mean ICU was 2.2 ± 2.5 and 5.0 ± 11.7 days in isolated AVR and combined surgery respectively (p=0.01). Hospital stay were and 7.1 ± 4.1 and 9.6 ± 15.7 days in isolated AVR and in combined surgery respectively (p=ns).Thirty-day mortality occurred in 2 patients (1.3%) one in isolated AVR population and one in a concomitant mitral valve repair procedure. Five patient (3.3%) needed a surgical re-exploration for postoperative bleeding (4 in combined surgery group, p=ns). No major neurological events were observed.CONCLUSIONS: This study shows that through a single port endoscopic approach made for AVR a concomitant procedure is feasible and safe in experienced centers. Concomitant surgery can include multiple valve treatment and endoscopically complex operation as the ascending aorta replacement. Additional procedures cause a statistically significant elongation of CPB and cross clamp time and ICU stay, without affecting overall mortality in our series.
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