International Society For Minimally Invasive Cardiothoracic Surgery

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Rapid Deployment Aortic Valve Replacement Via Right Lateral Mini Thoracotomy; First Clinical Experience In Japan
Hiroki Hata, Koichi Toda, Shigeru Miyagawa, Yasushi Yoshikawa, Daisuke Yoshioka, Satoshi Kainuma, Takuji Kawamura, Ai Kawamura, Yoshiki Sawa.
Osaka University Graduate School of Medicine, Suita, Japan.

Background: Rapid deployment aortic valve replacement (RDAVR) has been developed to shorten procedural times and facilitate minimally invasive cardiovascular surgery (MICS). Although MICS-RDAVR (mainly via right anterior mini-thoracotomy) has been widely performed in many countries, RDAV has not yet been commercially available in Japan. We report 2 cases of MICS-RDAVR via right lateral mini-thoracotomy using the INTUITY Elite Valve System (Edwards Life Sciences, Irvine, CA, USA) as the first clinical usage in Japan. Methods: Two female patients suffering from severe aortic stenosis underwent MICS-RDAVR. A 7 to 8-cm skin incision was made below the edge of the pectoralis major muscle and a right lateral mini-thoracotomy was performed through the third intercostal space. Because both patients had atherosclerotic change in the descending aorta, cardiopulmonary bypass was established via a vascular graft in the right axillary artery in one patient, and in another patient, a 14-Fr outflow cannula was inserted in both the right femoral artery and the ascending aorta and retrograde arterial perfusion was maintained within 2 L/min to avoid the risk of neurological complications. The size of aortic annulus was 25-mm and 24-mm each. Therefore, a 23-mm and 21-mm INTUITY Elite valve was implanted using three equidistant guiding sutures. The myocardial ischemic time was 122 and 138 minutes, respectively. Results: The patients recovered quickly and were discharged from hospital without significant adverse events. Although the first patient presented with paroxysmal atrial fibrillation and the second patient transiently developed complete atrioventricular block, regular sinus rhythm was spontaneously recovered soon in each case. Postoperative transthoracic echocardiography revealed no perivalvular leakage and acceptable aortic gradient (mean, 12 and 11 mmHg) and valve area (2.01 and 1.54 cm2). Both patients were sent home without heart failure symptoms. Conclusions: MICS-RDAVR via right mini-thoracotomy was performed safely and successfully using the INTUITY Elite Valve System for the first time in Japan in a clinical setting. Because we are still on the learning curve, further investigations are mandatory to elucidate potential benefits of MICS-RDAVR using the INTUITY Elite Valve System, via right lateral mini-thoracotomy.

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