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A study compared the outcomes of minimally invasive aortic valve replacement (AVR) through right mini-thoracotomy (RAMT) and full sternotomy (FS) in obese patients with a body mass index (BMI) over 30. The research involved 451 patients at three cardiac centers in Germany, with 336 undergoing RAMT and 115 FS. Results showed that RAMT was as safe and effective as FS, with lower rates of wound healing issues and shorter postoperative ventilation times. The study suggests that obesity should not be a barrier to minimally invasive AVR via RAMT. [Extracted from the article]

This article discusses the safety and efficacy of minimally invasive aortic valve replacement (AVR) through right anterior mini-thoracotomy (RAMT) in obese patients with a body mass index (BMI) over 30. The study, conducted in Germany, included 336 patients and found a 30-day mortality rate of 1.8% and in-hospital mortality rate of 2.1%. The results showed that RAMT was a safe and effective option for obese patients, with promising respiratory outcomes and reduced need for post-extubation support. [Extracted from the article]

The article discusses a multicentric retrospective study on minimally invasive aortic valve replacement through right mini-thoracotomy in patients with heart failure. The study aimed to investigate clinical outcomes following AVR via RAMT in patients with reduced LVEF (≤40%) and evaluate the significance of left ventricular dysfunction on perioperative outcomes. Results showed that the procedure was safe and effective, with low mortality and morbidity rates, even in patients with heart failure, and was associated with short ICU and hospital stays. [Extracted from the article]

The article reports on the midterm outcomes of surgical aortic valve replacement (SAVR) using bioprosthetic valves in young patients with pre-existing comorbidities. The study, based on the IMPACT registry, followed 556 patients for 3 years and found favorable survival rates, improved hemodynamic performance, and functional status post-SAVR. The results indicate a decrease in left ventricular volume and mass index, improved ejection fraction, and reduced aortic valve gradient, with low rates of complications such as prosthetic endocarditis and paravalvular leak. [Extracted from the article]

The article compares the outcomes of minimally invasive surgery via right anterolateral mini-thoracotomy (RAMT) access versus complete sternotomy (CS) in patients undergoing replacement of the ascending aorta (AA) and the aortic root. The study found that RAMT had shorter aortic x-clamp time, lower 30-day mortality, and fewer complications such as wound infections, postoperative delirium, and re-intubation compared to CS. The authors recommend adopting the RAMT approach for aortic surgery to reduce sternotomy-associated complications and improve postoperative outcomes. [Extracted from the article]

The article compares the outcomes of minimally invasive surgery for replacing the ascending aorta and aortic root using two different approaches: right anterolateral mini-thoracotomy (RAMT) and partial upper sternotomy (PUS). The study analyzed data from 96 patients and found that RAMT had shorter operation times and lower rates of complications compared to PUS. The authors recommend RAMT as a safe and effective technique for treating these conditions when performed by an experienced team in a high-volume center. [Extracted from the article]

This article discusses the feasibility of using ultrasonic decalcification as a minimally invasive approach for treating mitral annular calcification (MAC) in valve surgery. The study involved 5 patients who underwent the procedure, which involved cautious debulking of the mitral annulus prior to valve replacement. The results showed that the procedure was successful, with no complications or adverse events observed. The authors suggest that MAC may no longer require open surgery in selected patients and recommend further evaluation with larger patient cohorts. [Extracted from the article]

This article, published in the journal Thoracic & Cardiovascular Surgeon, examines the prevention of re-thoracotomy in patients who have undergone replacement of the ascending aorta. The study retrospectively analyzed the data of 267 patients who underwent this surgery and were divided into two groups based on whether they received an additional posterior left pericardiotomy (PLP) during the procedure. The results showed that patients who received PLP had a lower incidence of re-thoracotomy and postoperative atrial fibrillation, without an increased risk of postoperative complications. However, these patients did have a higher rate of stroke. Overall, the study suggests that PLP may be a beneficial surgical maneuver in preventing certain complications in patients undergoing this type of surgery. [Extracted from the article]

Introduction: Endoscopic minimally invasive valve surgery is a promising alternative to valve surgery through median sternotomy. Our study compared the short-term outcomes of patients undergoing endoscopic minimally invasive multiple concomitant valve surgeries (MIMVS) with median sternotomy (MS)., Methods: Demographic, clinical, and procedural data of all consecutive patients who underwent multiple-valve surgeries at two institutions in Germany from March of 2017 to March of 2023 were retrospectively collected. Patients were divided into two groups: MIMVS versus MS and their outcomes were compared before and after propensity score matching. Primary endpoint was the incidence of 30-day mortality., Results: A total of 317 patients were included in the study; 112 patients in each group were matched 1:1. MIMVS was performed on 123 patients. After propensity matching, 30-day mortality rates were 8% for MIMVS versus 12.5% for MS (p = 0.28). Median blood transfusion in the MIMVS group was 0 [0-3] vs 1 [0-4] in the MS group (p = 0.002). MIMVS was associated with similar cardiopulmonary bypass time 105.5 [79.8-124] versus 98 [68.8-130.3] mins and aortic cross clamping times 70 [53-80.3] versus 63.5 [46-90.3] mins (p values 0.9 and 0.76, respectively). Median intensive care and inhospital stays were similar between both groups (2 [1-4] vs 2 [1-5] days, p = 0.36, and 12 [8-17] vs 12.5 [9-21] days, p = 0.38). Incidences of intrathoracic bleeding, stroke, and acute kidney injury were similar in both groups., Conclusions: In our experience, endoscopic minimally invasive multiple-valve surgeries through right anterior mini-thoracotomy is as feasible, safe, and effective as medial sternotomy in select patients., Competing Interests: Declarations. Conflict of Interest: Farhad Bakhtiary reports a relationship with Edwards Lifesciences that includes: consulting or advisory and speaking and lecture fees. Farhad Bakhtiary reports a relationship with Medtronic that includes: consulting or advisory and speaking and lecture fees. Farhad Bakhtiary reports a relationship with LSI that includes: speaking and lecture fees. Saad Salamate, Ali Bayram, Miriam Silaschi, Omur Akhavuz, Mirko Doss, Sami Sirat, and Ali El-Sayed Ahmad declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethical Approval: The study was approved by the respective institutional review boards (Medical Association of North Rhine number 82/2021, local ethics board of the University of Bonn number 169/20). Individual patient consent for the study was waived., (© 2024. The Author(s).)

The advancement of micro-invasive cardiac surgery techniques has introduced a viable alternative to conventional full-sternotomy operations. These approaches are designed to reduce tissue trauma, shorten recovery time, and meet the increasing demand for less invasive treatment options. In this review, we discuss current progresses in endoscopic micro-invasive cardiac surgery, which utilizes refined tools and advanced imaging technologies to perform complex heart procedures, including valve surgery, coronary artery bypass grafting, and congenital defect corrections. By reviewing our experience with these techniques, we provide practical insights for surgeons interested in adopting micro-invasive cardiac surgery. The highlighted innovations in planning and execution of micro-invasive cardiac surgery reflect the growing trend toward safer and more efficient cardiac surgeries., Competing Interests: Conflict of Interest: Farhad Bakhtiary reports a relationship with Edwards Lifesciences, Medtronic and LSI that includes consulting or advisory and speaking and lecture fees. All other authors have nothing to disclose with regard to commercial support., (Copyright © 2024, Turkish Society of Cardiovascular Surgery.)

Objectives: We investigated the sex-related difference in characteristics and 2-year outcomes after surgical aortic valve replacement (SAVR) by propensity-score matching (PSM)., Methods: Data from 2 prospective registries, the INSPIRIS RESILIA Durability Registry (INDURE) and IMPACT, were merged, resulting in a total of 933 patients: 735 males and 253 females undergoing first-time SAVR. The PSM was performed to assess the impact of sex on the SAVR outcomes, yielding 433 males and 243 females with comparable baseline characteristics., Results: Females had a lower body mass index (median 27.1 vs 28.0 kg/m2; P = 0.008), fewer bicuspid valves (52% vs 59%; P = 0.036), higher EuroSCORE II (mean 2.3 vs 1.8%; P < 0.001) and Society of Thoracic Surgeons score (mean 1.6 vs 0.9%; P < 0.001), were more often in New York Heart Association functional class III/IV (47% vs 30%; P < 0.001) and angina Canadian Cardiovascular Society III/IV (8.2% vs 4.4%; P < 0.001), but had a lower rate of myocardial infarction (1.9% vs 5.2%; P = 0.028) compared to males. These differences vanished after PSM, except for the EuroSCORE II and Society of Thoracic Surgeons scores, which were still significantly higher in females. Furthermore, females required smaller valves (median diameter 23.0 vs 25.0 mm, P < 0.001). There were no differences in the length of hospital stay (median 8 days) or intensive care unit stay (median 24 vs 25 hours) between the 2 sexes. At 2 years, post-SAVR outcomes were comparable between males and females, even after PSM., Conclusions: Despite females presenting with a significantly higher surgical risk profile, 2-year outcomes following SAVR were comparable between males and females., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: To overcome some of the challenges of endoscopic minimally invasive valve surgery, an automated annular suturing device has been used in aortic and mitral valve replacement surgeries. The current study investigates early clinical outcomes of patients who received aortic or mitral valve replacement with the help of the RAM® device as first experiences in minimally invasive valve surgery., Methods: Between September 2020 and June 2023, 66 consecutive patients (mean age 61.8 ± 11 years) underwent endoscopic minimally invasive aortic or mitral valve replacement through right anterior mini-thoracotomy at 2 cardiac surgery referral centres in Germany. The RAM® device was used in all Patients. 3.5 and 5.0 sizes were used in 16.7% and 83.3% of patients, respectively. Aortic, mitral and double valve surgery was performed in 81.8%, 15.2% and 1.5% of patients, respectively. Clinical data were prospectively entered into our institutional database., Results: Cardiopulmonary bypass time and cross-clamping time were 97.9 ± 20.9 and 66 ± 15.7 min, respectively. Intensive care unit and hospital stays were 1 [1-2] and 9 [7-13] days, respectively. No paravalvular leak and no other intraoperative complications occurred. 30-day and in-hospital mortality were zero. Conversion to sternotomy occurred in 1 (1.5%) patient due to bleeding., Conclusions: The usage of the RAM® device is a safe, feasible and effective approach to the endoscopic implantation of aortic or mitral valves and yield excellent early outcomes. Larger size studies are needed to evaluate the efficacy and safety of RAM® device., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background/Objectives : The minimally invasive approach through left mini-thoracotomy is a promising alternative to the median sternotomy for coronary artery bypass. The aim of this study was to compare the short-term outcomes of patients undergoing minimally invasive coronary artery bypass (MIDCAB) with off-pump coronary artery bypass through sternotomy (OPCAB) for single-vessel disease. Methods : From January 2017 to February 2023, 377 consecutive patients aged above 18 years undergoing off-pump bypass of the left anterior descending artery (LAD) with left internal thoracic artery underwent OPCAB. Propensity score matching was then applied. Primary endpoints were in-hospital mortality and 30-day mortality. Results : Prior to matching, 30-day mortality occurred in 2 (0.7%) patients in the MIDCAB group vs. 1 (1%) patient in the OPCAP group ( p = 1). Transfusion of red blood cells (RBC) was required in 9.4% and 29% of patients within the MIDCAB and the OPCAB groups, respectively ( p < 0.001). Median intensive care stay (ICU) was 1 [1-2] day in the MIDCAB group, vs. 2 [1-3] in the OPCAB ( p < 0.001). In the matched cohort, 10% of MIDCAB patients received RBCs vs. 27.5% of OPCAB patients ( p = 0.006). Median ICU stay was significantly lower in the MIDCAB group, 1 [1-2] vs. 2 [1-3] days. Conclusions : MIDCAB is as safe and effective as OPCAB for single coronary artery bypass of the LAD with the LITA in select patients. It is associated with a decreased ICU stay and lower transfusion rates when compared with OPCAB.

Objectives: Patients with failed stentless aortic prostheses are a challenging population to treat, as reoperative procedures may be complex and catheter-based treatments are associated with a high rate of procedural events. Reoperative surgery using sutureless valves may be an alternative., Methods: In this multicentre experience, we assess outcomes of 17 patients who underwent reoperative surgery using the Perceval valve (Corcym UK Limited, London, UK) inside Freestyle prosthesis (Medtronic Inc., Dublin, Ireland) or bioroots from 2018 to 2023., Results: Mean age was 71.1 ±  standard deviation 15.1 years and mean EuroSCORE II was 13.5 ± 15.8%, Society of Thoracic Surgeons Score was 5.9 ± 11.7%. Mean transvalvular gradient at baseline was 25.3 ± 19.9 mmHg and left ventricular ejection fraction was 53.5 ±  standard deviation 8.5%. In 70.6% (12/17), moderate or severe aortic regurgitation was present. Implant success was 100%. Aortic cross-clamp time was 44.5 ±  standard deviation 23.6 min. No patient needed a pacemaker and no mild paravalvular regurgitation occurred. Mean gradient was 12.5 ± 4.7 mmHg; 30-day mortality was 5.9% (1/17)., Conclusions: Rate of mortality was lower than predicted by EuroSCORE II in these high-risk patients and haemodynamic outcomes were favourable. Heart teams should consider this treatment concept when discussing patients with failed stentless valves or bioroots., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background : Recently, minimally invasive access via right anterolateral mini-thoracotomy (RAMT) has been gaining popularity in cardiac surgery. This approach is also an option for surgeons performing aortic surgery. The aim of this study is to present our surgical method, highlighting the total endoscopic minimally invasive approach via RAMT for replacement of the ascending aorta (AAR) with or without involvement of the aortic root and the aortic valve. Methods : Clinical data of 44 patients from three participating institutions with AAR with or without involvement of the aortic valve or aortic root via RAMT between April 2017 and February 2024 were retrospectively analyzed. According to surgical procedure, patients were divided into two groups, in the AAR and in the Wheat/Bentall group with concomitant valve or root replacement. Operative time, length of ventilation, perioperative outcome, length of intensive care unit (ICU) as well as postoperative hospital stay, and mid- and long-term results were retrospectively analyzed. Results : Mean age was 61.4 ± 10.7 years old with a frequency of male gender of 63.6%. Mean cardiopulmonary bypass (CBP) time and aortic cross-clamping time was 94.9 ± 32.5 min and 63.8 ± 25.9 min, respectively. CPB and aortic clamp time were significantly lower in AAR group. In the first 24 h, the mean drainage volume was 790.3 ± 423.6 mL. Re-thoracotomy due to bleeding was zero. Sternotomy was able to be avoided in all patients. Patients stayed 35.9 ± 23.5 h at ICU and were discharged 7.8 ± 3.0 days following surgery from hospital. Mean ventilation time was 5.8 ± 7.6 h. All patients survived and 30-day mortality was 0.0%. At a median follow-up time of 18.2 months, all patients were alive. The results were similar in both groups. Conclusions : The full endoscopic RAMT approach with 3D visualization is a safe, feasible and promising technique that can be transferred in the field of aortic surgery without compromising surgical quality, postoperative outcomes, or patient safety when performed by an experienced team in a high-volume center.

Micro-invasive totally endoscopic aortic valve replacement surgery is a minimally invasive cardiac procedure that can be performed with the help of several techniques and technologies that employ the latest innovations in instrumentation and technological advances in the field, thereby greatly limiting the overall invasiveness of the procedure. With the help of a 3-dimensional camera, long instruments, a very small thoracotomy and a soft-tissue retractor without any rib retractor, the aortic valve can be easily and safely accessed for replacement. The other main features of these techniques are extracorporeal circulation that is achieved through peripheral percutaneous cannulation of the femoral vessels, antegrade cardioplegia, the use of automated devices for suturing the valvular ring and the prosthetic suture cuff, namely the RAM device, the Sew-Easy device and the Cor-Knot Mini device. Additionally, an automated vascular closure device such as the MANTA device is later used to close the femoral artery following decannulation., (© The Author 2024. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Dextrocardia with situs inversus totalis is a rare congenital condition. We report herein a first experience of video-assisted minimally invasive mitral and pulmonary valve replacement through right anterior mini-thoracotomy as reoperation in patient with this complex anomaly. The good clinical and cosmetic results demonstrate that this innovative technique can be safely performed even in difficult anatomical conditions., Competing Interests: FB discloses speakers' honoraria and/or consulting fees from Edwards Lifesciences, LIS and Abbott. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Salamate, El-Sayed Ahmad, Bayram, Sirat and Bakhtiary.)

Background: Transmitral myectomy for symptomatic hypertrophic obstructive cardiomyopathy is possible with existence of substantial mitral valve disease. We present herein our experience of minimally invasive transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy in the past 4 years at our institution., Methods: Between March 2017 and October 2020, 14 patients with hypertrophic obstructive cardiomyopathy and mitral valve disease required minimally invasive transmitral septal myectomy combined with mitral valve reconstruction or replacement at our institution. Mean age of patients was 54.2 ± 11.4 and 42.9% ( n  = 6) were female. Twelve patients (85.1%) were in New York Heart Association class III to IV and 6 patients (42.9%) presented with persistent atrial fibrillation. Clinical data were prospectively entered into our institutional database., Results: Cardiopulmonary bypass time accounted for 140.2 ± 32.6 minutes and the myocardial ischemic time was 78.5 ± 12.4 minutes. Thirty-day mortality and overall mortality were zero. Peak ventricular outflow gradient decreased from 75.2 ± 12.7 to 9.4 ± 2.3 mm Hg ( p  < 0.0001). Simultaneously, mitral valve reconstruction and replacement were performed in 11 (78.6%) and 3 (21.4%) patients, respectively. No systolic anterior motion was seen in patients with mitral valve repair. No conversion to full sternotomy and/or rethoracotomy was noted. During a mean follow-up period of 24 ± 13 months, no patient required reoperation, no recurrence mitral regurgitation, and left ventricular outflow tract obstruction., Conclusion: Transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy can be performed safely with excellent surgical outcomes., Competing Interests: None declared., (Thieme. All rights reserved.)

Since its inception more than a quarter of a century ago, minimally invasive cardiac surgery has attracted the increasing interest of cardiac surgeons worldwide. The need to surgically treat patients with smaller and better-tolerated incisions coupled with high-quality clinical outcomes, particularly in structural heart disease, has become imperative to keep pace with the evolution of transcatheter valve implantation. We have learned numerous lessons from our longstanding experience in this field of surgical care, especially in terms of endoscopic access via mini-thoracotomy. To improve the safety and efficacy of this minimally invasive endoscopic access, this study summarizes and highlights the lessons we have learned, acting as a template for newly established cardiac surgeons in minimally invasive techniques., Competing Interests: FB discloses speakers' honoraria and/or consulting fees from Edwards Lifesciences, LIS, and Abbott. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 El-Sayed Ahmad, Salamate and Bakhtiary.)

Background and Aim: Bioprosthetic surgical aortic valve replacement (SAVR) is increasingly adopted in younger patients. We aimed to analyze mid-term follow-up data after SAVR to assess the performance of the prosthesis., Methods: Data were collected from a single-center series of 154 patients, who underwent SAVR with a bioprosthetic heart valve with the RESILIA tissue at our Heart Centre in Siegburg. All procedural and midterm patient outcomes were documented., Results: Patients had a mean age of 56.8 ± 9.9 years, 35.7% were female, and the mean logistic European system for cardiac operative risk evaluation (EuroSCORE) was 3.4 ± 3.6%. Diabetes (12.3%), atrial fibrillation (10.4%), and chronic obstructive pulmonary disease (COPD) (5.8%) were common comorbidities. The mean surgery duration was 163.8 ± 73.4 min, with the 23 mm (34.4%) and 25 mm (33.8%) heart valves being most frequently implanted. At 3-year follow-up, mean pressure gradient was 13.9 ± 5.9 mmHg, peak gradient was 23.6 ± 7.7 mmHg, and effective orifice area (EOA) was 1.9 ± 0.4 cm². No patient died during the operation, 3 (2.1%) patients within 30 days, and 4 (2.7%) thereafter with an overall mortality of n = 7. Of the surviving patients, 97.8% were in New York Heart Association (NYHA) class I/II and none had structural valve deterioration (SVD)., Conclusion: Results of our single-center study indicate favorable procedural outcomes. The safety outcomes confirm preliminary earlier results of this novel bioprosthesis but include more patients and a longer midterm follow-up., (© 2022 Wiley Periodicals LLC.)

Introduction: Propensity score analysis of midterm outcomes after isolated aortic valve replacement through right anterior mini-thoracotomy and partial upper sternotomy could provide information about the most beneficial minimally invasive technique for the patient based on the preoperative risk factors., Methods: Between March 2015 and February 2021, 694 minimally invasive isolated aortic valve surgeries were performed at our institution. Among these, 441 right anterior mini-thoracotomies and 253 partial upper sternotomies were performed. A propensity score analysis was performed in 202 matched pairs., Results: Cardiopulmonary bypass time and cross-clamp time were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.001 and p < 0.001, respectively). Time to first mobilization and hospital stay were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.005, p = 0.001, respectively). A significantly lower incidence of revision surgery was noted in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.046). No significant differences in 30-day mortality (p = 1.000) and 1-year mortality (p = 0.543) were noted. Kaplan-Meier survival estimates were 96.3% in the right anterior mini-thoracotomy group and 92.7% in the partial upper sternotomy group after 4 years (log rank 0.169), respectively., Conclusions: Despite the technical challenges, right anterior mini-thoracotomy can be chosen as first-line strategy for isolated aortic valve replacement. For patients unsuitable for this technique, the partial upper sternotomy remains a safe method that can be performed by a wide range of surgeons., (© 2022. The Author(s).)

Objectives: Extensive infective endocarditis (IE) stays a serious life-threatening disease with high mortality and morbidity. The aim of this study is to analyse our experience with our modified surgical technique for extensive IE during the last 4 years., Methods: Between March 2017 and February 2021, all patients with extensive IE required our modified technique consisting of a radical surgical resection of all infected cardiac tissues, the replacement of infected valves and a reconstruction of the intervalvular fibrous body, the aortic root and the left ventricular outflow tract with modified elephant trunk were included in this study., Results: Our modified technique was performed on 41 patients during the study period. The age median was 74 [interquartile range (IQR): 66.5-76.5] and 61.0% (n = 25) were female. Thirty-three patients (80.5%) were in New York Heart Association Class III-IV and 7 patients (17.1%) in cardiogenic shock. The median logistic European system for cardiac operative risk evaluation II as predicted risk of mortality was 35% (IQR: 28-78%). The median cardiopulmonary bypass time and cross-clamping time were 126 (IQR: 86.5-191) and 78 (IQR: 55.5-108) min, respectively. Intraoperative mortality and 30-day mortality were 4.8% (2 patients) and 19.5% (8 patients), respectively. Low cardiac output with necessity for mechanical support, stroke and new renal dialysis developed in 9.8% (4 patients), 17.1% (7 patients) and 22.0% (9 patients), respectively. New pacemaker implantation was noted in 39.0% (16 patients). Intensive care stay and hospital stay had medians of 6 (IQR: 5-12) and 14 (IQR: 12.5-20.5) days, respectively. One-year mortality and 4-year mortality were 34.1% (14 patients) and 39.0% (16 patients), respectively. Kaplan-Meier survival estimates were 60.3% (95% confidence interval: 46.2-78.6%) at 3 years., Conclusions: Our modified technique can be performed in patients with extensive IE with acceptable early and mid-term morbidity and mortality. We believe that this technique is an available option for this ill-fated group of patients., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Both surgical and percutaneous femoral accesses for the establishment of extracorporeal circulation are used in minimally invasive cardiac surgeries. The goal of this study was to compare the outcomes with the MANTA vascular closure device after percutaneous arterial decannulation via the surgical approach., Methods: Between November 2018 and January 2021, a total of 490 consecutive patients underwent minimally invasive cardiac operations at our institution. Cannulation and decannulation of femoral vessels were under direct vision surgically or percutaneously. The MANTA system was used to close the femoral artery in all patients with percutaneous cannulation. Demographic, clinical and procedural data were collected retrospectively., Results: Surgical cut-down and suture closure of the femoral artery was performed in 222 patients (45.3%); percutaneous access and closure with the MANTA system was used in 268 patients (54.7%). The surgical group presented a significantly higher incidence of any access site complication compared to the percutaneous group [18 patients (8.1%) vs 6 patients (2.2%); P = 0.003]. Lymph fistula and wound healing disorders occurred more frequently in the surgical group (3.2% vs 0% [P = 0.004] and 3.6% vs 0% [P = 0.002], respectively). Median procedural duration and stays in the intensive care unit were significantly lower in the percutaneous group {127 [interquartile range (IQR) 97-158] min vs 150 (IQR 117-185) min (P < 0.001) and 1 (IQR 1-2) day vs 2 (IQR 1-3) days (P = 0.008), respectively}., Conclusions: Percutaneous access and closure with the MANTA system are feasible, safe and associated with lower incidences of all-cause access site complications and shorter stays in the intensive care unit compared to surgical access and closure in minimally invasive cardiac surgeries., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background:  To more minimize the minimally invasive valve surgeries, percutaneous vascular access and closure has been used for the establishment of extracorporeal circulation. This study investigates early clinical outcomes of patients who received MANTA for femoral artery closure as first experiences in minimally invasive valve surgery., Methods:  Between January 2019 and July 2019, 103 consecutive patients (mean age: 58 ± 11 years) underwent video-assisted minimally invasive valve surgery through right anterior minithoracotomy at two cardiac surgery referral centers in Germany. Percutaneous cannulation for cardiopulmonary bypass and femoral artery closure with MANTA were performed in all patients: 18-F and 14-F MANTA were used in 88 (85.4%) and 15 (14.6%) patient, respectively. Mitral, aortic, tricuspid, and double valve surgeries were performed in 51 (49.5%), 39 (37.9%), 7 (6.8%), and 6 (5.8%), patients, respectively. Clinical data were prospectively entered into our institutional database., Results:  Cardiopulmonary bypass time and cross-clamping time were 69 ± 23 and 38 ± 14 minutes, respectively. Except for two patients with late pseudoaneurysm on 15th and 23th postoperative day, neither major nor minor vascular complications nor vascular closure device failure according to the Valve Academic Research Consortium-2 definition criteria was observed. Additionally, no wound healing disorders or conversion to surgical closure was observed., Conclusions:  MANTA as percutaneous femoral artery closure after decannulation of cardiopulmonary bypass is a safe, feasible, and effective approach and yields excellent early outcomes. Larger size studies are needed to evaluate more the efficacy and safety of MANTA., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: Aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is less traumatic than via other surgical routes; using a novel aortic valve may confer long-term resistance against valve deterioration, and thus be useful in younger, more active patients. Here we aim to validate using the INSPIRIS RESILIA valve with minimally invasive RAMT., Methods: Between April 2017 and June 2019, 100 patients underwent video-assisted minimally invasive AVR by RAMT, using the INSPIRIS RESILIA aortic valve. Cannulation for cardiopulmonary bypass (CPB) was through femoral vessels. Clinical data were prospectively entered into our institutional database., Results: Cardiopulmonary bypass (CPB) and cross-clamping times were 79 ± 38 and 41 ± 17 min. Surgical access was successful in 100% of cases. There were no cases of intraoperative mortality, 30-day mortality, cerebrovascular events, rethoracotomy for bleeding, valve-related reoperation, right internal mammary artery injury, or conversion to sternotomy. Intensive care and hospital stays were 2 ± 1 and 6 ± 3 days, respectively. One patient had a pacemaker fitted. Postoperative dialysis was necessary in one patient. Trace to mild aortic valve regurgitation occurred in two patients. No structural valve deterioration (SVD) and paravalvular leak were seen. At 1-year follow-up mean effective orifice area (EOA) was 1.8 ± 0.1 cm 2 , peak gradient was 22.1 ± 3.1 mmHg, and mean gradient was 11.5 ± 2.3 mmHg., Conclusion: Our preliminary experience suggests that RAMT for AVR using the INSPIRIS RESILIA aortic valve is safe, effective, and reproducible. Larger studies are needed to evaluate the long-term efficacy and durability of this new valve.

Background: Degenerative aortic valve disease accounts for 10-20% of all cardiac surgical procedures. The impact of pre-existing comorbidities on the outcome of patients undergoing surgical aortic valve replacement (SAVR) needs further research., Methods: The IMPACT registry is a non-interventional, prospective, open-label, multicenter, international registry with a follow-up of 5 years to assess the impact of pre-existing comorbidities of patients undergoing SAVR with the INSPIRIS RESILIA aortic valve on outcomes. IMPACT will be conducted across 25 sites in Austria, Germany, The Netherlands and Switzerland and intends to enroll approximately 500 patients. Patients will be included if they are at least 18 years of age and are scheduled to undergo SAVR with the INSPIRIS RESILIA Aortic Valve with or without concomitant ascending aortic root replacement and/or coronary bypass surgery. The primary objective is to determine all-cause mortality at 1, 3, and 5 years post SAVR. Secondary objectives include cardiac-related and valve-related mortality and structural valve deterioration including hemodynamics and durability, valve performance and further clinical outcomes in the overall study population and in specific patient subgroups characterized by the presence of chronic kidney disease, hypertension, metabolic syndrome and/or chronic inflammation., Discussion: IMPACT is a prospective, multicenter European registry, which will provide much-needed data on the impact of pre-existing comorbidities on patient outcomes and prosthetic valve performance, and in particular the performance of the INSPIRIS RESILIA, in a real-world setting. The findings of this study may help to support and expand appropriate patient selection for treatment with bioprostheses., Trial Registration: ClinicalTrials.gov identifier: NCT04053088 .

Objective: Right anterior minithoracotomy is a promising technique for aortic valve replacement and has shown excellent results in terms of mortality and morbidity. Against this background, we analyzed our institutional experience in this technique during the last 3 years., Methods: Between April 2017 and March 2019, 513 consecutive all comers with aortic valve disease underwent video-assisted minimally invasive aortic valve replacement through a 3-cm skin incision as right anterior minithoracotomy at our institution. A camera and automatic fastener technology were used for the valve implantation in all patients. Clinical data were prospectively entered into our institutional database., Results: Cardiopulmonary bypass time accounted for 68 ± 24 min and the myocardial ischemic time 38 ± 12 minutes. Thirty-day mortality and overall mortality was 0.4% (2 patients) and 1.4% (7 patients), respectively. Postoperative cerebrovascular events were noted in 8 patients (1.5%). Intensive care stay and hospital stay were 2 ± 2 and 9 ± 7 days, respectively. Pacemaker implantation, injury of the right internal mammary artery, and conversion to full sternotomy were noted in 7 patients (1.4%), 3 patients (0.6%), and 1 patient (0.2%), respectively. Paravalvular leak need to intervention was noted in 2 patients (0.4%). Rethoracotomy rate was 2% (11 patients). Transient postoperative dialysis was necessary for 14 patients (3%)., Conclusions: Video-assisted minimally invasive aortic valve replacement through the right anterior minithoracotomy is a safe approach and yields excellent outcomes in high-volume centers. The use of a camera and automatic fastener technology facilitates this procedure.