IntroductionNumbers of patients undergoing mitral valve repair (MVr) surgery for severe mitral regurgitation have grown and will continue to rise. MVr is routinely performed via median sternotomy; ...however, there is a move towards less invasive surgical approaches.There is debate within the clinical and National Health Service (NHS) commissioning community about widespread adoption of minimally invasive MVr surgery in the absence of robust research evidence; implementation requires investment in staff and infrastructure.The UK Mini Mitral trial will provide definitive evidence comparing patient, NHS and clinical outcomes in adult patients undergoing MVr surgery. It will establish the best surgical approach for MVr, setting a standard against which emerging percutaneous techniques can be measured. Findings will inform optimisation of cost-effective practice.Methods and analysisUK Mini Mitral is a multicentre, expertise based randomised controlled trial of minimally invasive thoracoscopically guided right minithoracotomy versus conventional sternotomy for MVr. The trial is taking place in NHS cardiothoracic centres in the UK with established minimally invasive mitral valve surgery programmes. In each centre, consenting and eligible patients are randomised to receive surgery performed by consultant surgeons who meet protocol-defined surgical expertise criteria. Patients are followed for 1 year, and consent to longer term follow-up.Primary outcome is physical functioning 12 weeks following surgery, measured by change in Short Form Health Survey (SF-36v2) physical functioning scale. Early and 1 year echo data will be reported by a core laboratory. Estimates of key clinical and health economic outcomes will be reported up to 5 years.The primary economic outcome is cost effectiveness, measured as incremental cost per quality-adjusted life year gained over 52 weeks following index surgery.Ethics and disseminationA favourable opinion was given by Wales REC 6 (16/WA/0156). Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer reviewed publication.Trial registration numberISRCTN13930454.
Medical management of atrial fibrillation can be complex, challenging and requiring time to prove its effectiveness; furthermore, the response can be refractory and inconsistent if the underlying ...pathology is not permanently addressed. Surgical ablation has become a key intervention, and since its first intervention in 1987 (the Cox-maze procedure), the technique has evolved from a conventional open method to a minimally invasive technique whilst retaining excellent outcomes. Furthermore, recent advances in the use of a hybrid approach have been established as satisfactory approach in managing atrial fibrillation with satisfactory outcomes. This literature review focuses on the evidence behind the surgical success in managing atrial fibrillation throughout the past, present and the future of these surgical interventions.
Unilateral diaphragmatic agenesis is a rare finding in adult patients. We herein present the case of a 24-year-old male patient who was diagnosed and surgically treated for the complete absence of ...the left hemidiaphragm. His symptoms included acute respiratory distress, ipsilateral absence of breath sounds, and vague abdominal discomfort. A neodiaphragm was created via a left thoracotomy using synthetic material. The postoperative course was uneventful, and the patient is in satisfactory condition 9 months after the operation. This is only the seventh known case of unilateral diaphragmatic agenesis reported in the literature.
Background: The aging of the population has resulted in an increasing number of elderly patients undergoing cardiac operations. We reviewed our experience in patients over the age of 80 undergoing ...primary aortic valve replacement (AVR) with or without CABG. Methods: Between 2000 and 2008, 345 patients (226 male) ≥80 years underwent primary AVR in our unit. The notes of these patients were retrospectively reviewed and follow‐up information was obtained from their general practitioners. They had a mean age of 82.9 ± 2.3 years and a median logistic EuroSCORE of 13.4 (IQR 9.4, 19.1). Isolated AVR was performed in 161 patients (45.5%), and 184 (51.6%) patients underwent combined AVR and CABG. A quality of life questionnaire was sent to all survivors. Results: Hospital mortality occurred in 17 patients (4.9%), which was significantly lower than the mortality predicted by logistic EuroSCORE (16.2%, p < 0.01). Hospital mortality was comparable between patients undergoing isolated AVR and those undergoing additional CABG (4.3% vs. 5.4%, respectively). Actuarial survival at one and five years was 90.1 ± 1.6% and 77.2 ± 2.9%, respectively. There was a 62% response on the questionnaire showing 70% of the patients were NYHA I and 83.7% were satisfied with the operation outcome. Conclusions: AVR can be undertaken with excellent results in octogenarians and the current risk is significantly lower than what is predicted with conventional risk‐scoring systems. Patients with advanced age should not necessarily be excluded from being candidates for AVR. (J Card Surg 2011;26:466‐471)
The safety and effectiveness of mitral valve repair via thoracoscopically-guided minithoracotomy (minithoracotomy) compared with median sternotomy (sternotomy) in patients with degenerative mitral ...valve regurgitation is uncertain.
To compare the safety and effectiveness of minithoracotomy vs sternotomy mitral valve repair in a randomized trial.
A pragmatic, multicenter, superiority, randomized clinical trial in 10 tertiary care institutions in the UK. Participants were adults with degenerative mitral regurgitation undergoing mitral valve repair surgery.
Participants were randomized 1:1 with concealed allocation to receive either minithoracotomy or sternotomy mitral valve repair performed by an expert surgeon.
The primary outcome was physical functioning and associated return to usual activities measured by change from baseline in the 36-Item Short Form Health Survey (SF-36) version 2 physical functioning scale 12 weeks after the index surgery, assessed by an independent researcher masked to the intervention. Secondary outcomes included recurrent mitral regurgitation grade, physical activity, and quality of life. The prespecified safety outcomes included death, repeat mitral valve surgery, or heart failure hospitalization up to 1 year.
Between November 2016 and January 2021, 330 participants were randomized (mean age, 67 years, 100 female 30%); 166 were allocated to minithoracotomy and 164 allocated to sternotomy, of whom 309 underwent surgery and 294 reported the primary outcome. At 12 weeks, the mean between-group difference in the change in the SF-36 physical function T score was 0.68 (95% CI, -1.89 to 3.26). Valve repair rates (≈ 96%) were similar in both groups. Echocardiography demonstrated mitral regurgitation severity as none or mild for 92% of participants at 1 year with no difference between groups. The composite safety outcome occurred in 5.4% (9 of 166) of patients undergoing minithoracotomy and 6.1% (10 of 163) undergoing sternotomy at 1 year.
Minithoracotomy is not superior to sternotomy in recovery of physical function at 12 weeks. Minithoracotomy achieves high rates and quality of valve repair and has similar safety outcomes at 1 year to sternotomy. The results provide evidence to inform shared decision-making and treatment guidelines.
isrctn.org Identifier: ISRCTN13930454.
Aorto‐innominate artery bypass for migrated stent Chong, Jun Heng; Harky, Amer; Badran, Abdul ...
Journal of cardiac surgery,
January 2021, 2021-Jan, 2021-01-00, Volume:
36, Issue:
1
Journal Article
Peer reviewed
Open access
We report a case of a 64‐year‐old female who first presented with a transient ischemic attack in 2007 due to an innominate artery stenosis, which indicated an endovascular stent placement. In 2008, ...she presented with recurrence of symptoms and was diagnosed with in‐stent restenosis alongside an unusual occurrence of retrograde migration into the ascending aortic arch. We performed an aorto‐innominate bypass through a median sternotomy. The patient was discharged without any complications thereafter, and the graft has shown excellent patency. As of 2019, the patient remains well.
•Longer operative times with transeptal approach in patients undergoing double valve surgery.•Higher rate of permanent pacemaker and atrial fibrillation in double valve surgery.•Similar outcomes, ...operatively and postoperatively, in isolated mitral valve surgery cases.
To compare outcomes of mitral valve surgery through conventional left atriotomy and transeptal approach (TS). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Primary outcomes were operative mortality and permanent pacemaker (PPM) implantation; secondary outcomes were new onset of atrial fibrillation (AF), stroke and operative times. Sixteen articles met the inclusion criteria with 4537 patients. Cardiopulmonary bypass was longer with TS (weighted mean differences - 16.44 minutes −29.53, −3.36, P = 0.01). Rates of PPM implantation (risk ratio 0.65 0.47, 0.89, P = 0.007) and new onset AF (risk ratio 0.87 0.78, 0.97, P = 0.02) were higher with TS. Subgroup analysis of isolated mitral valve surgery cohort showed no difference in operative times, mortality, new onset of AF, stroke, and PPM implantation. There is equal outcomes between both approaches during isolated mitral valve surgery; however, TS was associated with longer operative times and higher postoperative AF and PPM rates when pooling combined procedures. A large randomized controlled trial is required to confirm those findings.
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