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International Society For Minimally Invasive Cardiothoracic Surgery

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Ultra Fast Track Mini Mitral Surgery: Direct Trans-axillary Approach
Marco Di Eusanio1, Mariano Cefarelli1, Jacopo Alfonsi1, Walter Vessella2, Alessandro D'alfonso1, Luca Montecchiani1, Christopher Munch2, Paolo Berretta1.
1Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy, 2Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ancona, Italy.

Background. While the offer of minimally invasive interventions is gradually growing, patients' requests of interventions associated with minimized trauma and faster recovery remains often unfulfilled. Currently, most lines of progress in mini mitral surgery involves always more sophisticated and complex endoscopic support. Although such techniques are associated with excellent results from the most expert teams, they require steep learning curves thus limiting their dissemination. Based on that, we recently shifted from a classic endoscopic supported minimally invasive mitral valve intervention to a simplified trans-axillary direct access.Methods. Our approach involves:1) A single incision surgery; reducing the incisions means less pain and less bleeding2) direct access to the mitral valve through a 5 cm trans-axillary skin incision. This access allows direct exposition of the mitral valve with no visible incision from a front view. In fact, laterally the intercostal space is wider compared to more anterior accesses and the trans-axillary incision guarantees a 90 alignment with the mitral valve which is perfectly visualized at the center of the operative field.3) femoral vessels cannulation for cardiopulmonary bypass institution4) ultra fast track (UFT) anaesthesia with table extubation and early physiotherapy and family contact. Results. Between January 2017 and October 2019, 92 patients (mean age 63.1 years, Euroscore II 1.4%) underwent mini mitral surgery in our institution. Surgical procedure included mitral valve repair (n=87, 94.6%), and combined mitral and tricuspid valve repair (n=5, 5.4%). The mean cross clamp time was 72.8 23.9 minutes. No hospital death and postoperative stroke were observed. The main complications included renal failure (n=3, 3.2%), bleeding requiring revision (n=2, 1.1%) and respiratory insufficiency (n=1, 1.1%). The median ICU and hospital lengths of stay were 1 and 5 days, respectively.Conclusions.In our experience, UFT direct trans-axillary mini mitral surgery showed excellent results. We believe this approach presents several advantages over the other mini mitral accesses, allowing for no visible incision, no need for endoscopy which in turns results in a simpler, faster direct access surgery with maximally shortened learning curves and higher potential for dissemination.


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