Abstract


Over the past few decades, the field of minimally invasive cardiac surgery has significantly broadened. Novel surgical and endovascular techniques have been developed for the treatment of aortic valve pathologies. Surgical aortic valve replacement (SAVR) through a right antero-lateral (mini-)thoracotomy (RALT) has gained approval due to its limited postoperative trauma, faster rehabilitation and sufficient pain control. Nevertheless, SAVR RALT has not been adopted by a significant proportion of cardiac surgeons, due, in part, to its technical complexity and steep learning curve.
In this review, we discuss the data for minimally invasive aortic valve surgery and describe our operative technique for SAVR RALT.

Abstract


Composite replacement of the aortic root and aortic valve is a valid surgical strategy in a case of annuloaortic ectasia. However, valve-sparing root replacement procedures have become the gold standard in cases with a morphologically intact or at least repairable aortic valve, and offer several advantages compared to conventional replacement techniques. Above all, the David procedure has become established as a well-known valve-sparing root replacement strategy with excellent short- and long-term outcomes, and it has been further applied to additional patient populations with characteristics like a bicuspid aortic valve or in the setting of acute type A aortic dissection. This narrative review offers an overview of the indications as well as the surgical steps of the T. David V procedure, and highlights important key points regarding the surgical feasibility and criteria of patient selection for valve-sparing root replacement.

Abstract


Growing interest in minimalizing surgical trauma during heart procedures stimulated the development of robotic mitral valve surgery in the late 1990s. Initially, the new technology was slowly adopted in clinical practice. However, following encouraging results by teams that adopted robotic heart surgery early on, a growing interest in implementation of robotic mitral valve surgery has emerged. Of importance are the technical developments and possibilities that accompany robotic surgery.
Robotic arms feature unique characteristics, allowing unparalleled range of motion and allowing complex mitral valve repair techniques to be performed without limitations related to limited surgical incisions. High-quality three-dimensional vision effectively compensates for the lack of tactile feedback.
Several technical solutions have been developed to facilitate mitral valve repair in minimal invasive setting, including chordal guiding systems, now available with various annuloplasty rings. On the other hand, precise vision and movements allows accurate determination of the length of implanted neochordae, facilitating precise determination of the length of implanted neochords even without the use of chordal-guiding systems.
With robotic mitral valve surgery, leaflet resection techniques can be performed without limitations, ensuring that no compromises of the surgical strategy are made. Nevertheless, careful preoperative planning with appropriate work-up and imaging is of utmost importance to prevent complications. Moreover, the drawbacks of the initial learning curve and higher procedural costs are counterbalanced by less surgical trauma, lower utilization of blood products, and faster patient recovery. Robotic mitral valve surgery is still a young field and evolving technology that is bound to become an important tool in the toolbox of surgical mitral valve approaches.

Abstract


Patients affected by severe aortic root pathology require an operation to replace the dilated aortic root and repair or replace the aortic valve, which is very frequently involved in the disease. Among the surgical options available for aortic root replacement, the Bentall operation and the David aortic valve reimplantation procedure are the most commonly used by surgeons. This article provides an overview of the Bio-Bentall and David operations. It illustrates their surgical details and discusses the correct indications for both procedures to achieve excellent long-term outcomes. Finally, the authors present their experience with the physiologic treatment of aortic root pathology by using stentless Bio-conduits and David reimplantation in a cohort of patients with long-term follow-up. A comparative analysis of early and late results along with an evaluation of possible benefits and drawbacks related to each technique concluded that both procedures were effective in correcting the aortic root pathology, and the results were adequate and stable over time. Since hemodynamic performance was more improved after the David operation, it should be preferred, whenever feasible, in younger and active patients.

Abstract


Introduction: The importance of correcting tricuspid valve insufficiency in patients with left-sided valve disease is clear. In the United States, up to 30% of mitral valve operations are minimally invasive, while the data for isolated tricuspid valve is not known. A minimally invasive approach to the tricuspid valve provides faster recovery with lower transfusion rates and lower length of stay.
Materials and Methods: There are no dedicated right atrial (RA) retractors for minimally invasive tricuspid valve (TV) operations. TV exposure is different from mitral given the proximity of the tricuspid anterior annulus to the cut edge of the atrium. An RA retractor should be shallow while preventing slippage of the RA roof and should be quick to deploy and remove.
We created a dedicated minimally invasive RA retractor to expose the TV and RA structures (fossa ovalis and coronary sinus). The retractor is a fenestrated shallow and wide retractor with bilateral articulating “wings” to expose left and right of the atrium. This retractor is compatible with the left atrial system by USB Medical Limited (Hatboro, Pennsylvania) and has tilting capability. A three-dimensional (3D)-printed prototype was modified after evaluation by two experienced minimally invasive surgeons (MCS and RKV). Once modifications were finalized, the retractor was then deployed in surgery.
Results: The RA retractor was used in isolated TV repairs, RA myxoma resection, RA clot removal, removal of RA migrated stents, select mitral valve operations, and closure of atrial septal defects. The retractor proved effective, safe, and fast to deploy and remove and allowed for full visualization of the tricuspid valve, interatrial septum, ostia of both vena cavas, and coronary sinus. The retractor was useful in mitral valve operations with existing aortic valve prosthesis and in the small left atria.
Conclusion: The minimally invasive RA retractor affords excellent, stable exposure of the right atrial structures with fast deployment and removal.

Abstract


Background: Transplantation in the management of end-stage organ failure in patients with Anderson- Fabry disease is still a matter of debate due to a lack of data regarding long-term outcomes and prognosis.
Observations: Most of the cases in the literature did not receive enzyme-replacement therapy (ERT), or received it only years after transplantation. Based on our experience, we describe here the long-term results of heart transplant in combination with early ERT.
Conclusions: Transplantation combined with lifelong ERT should be considered to offer patients a chance of good long-term outcomes and quality of life.