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      Minimally invasive aortic valve replacement – pros and cons of keyhole aortic surgery

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          Abstract

          Over the last twenty years, minimally invasive aortic valve replacement (MIAVR) has evolved into a safe, well-tolerated and efficient surgical treatment option for aortic valve disease. It has been shown to reduce postoperative morbidity, providing faster recovery and rehabilitation, shorter hospital stay and better cosmetic results compared with conventional surgery. A variety of minimally invasive accesses have been developed and utilized to date. This concise review demonstrates and discusses surgical techniques used in contemporary approaches to MIAVR and presents the most important results of MIAVR procedures.

          Translated abstract

          Przez ostatnie 20 lat małoinwazyjna wymiana zastawki aortalnej (MIAVR) stała się bezpieczną, dobrze tolerowaną i skuteczną opcją leczenia chorób zastawki aortalnej. W porównaniu z tradycyjną sternotomią wykazano, że małoinwazyjna chirurgia zastawki aortalnej zmniejsza liczbę powikłań pooperacyjnych, zapewniając szybszą rehabilitację i powrót do zdrowia, krótszą hospitalizację jak również lepsze efekty kosmetyczne. Do chwili obecnej powstało wiele technik operacyjnych z małego dostępu. Poniższy artykuł przedstawia metody operacyjne oraz najbardziej istotne wyniki współczesnej małoinwazyjnej wymiany zastawki aortalnej.

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          Most cited references 42

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          Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.

          This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement. With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches. Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared. Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group. Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.
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            Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis.

            Most aortic valve replacements are by conventional full median sternotomy. Less invasive approaches have been developed with partial upper sternotomy (ministernotomy). Systematic review and meta-analysis were performed with studies comparing ministernotomy and full sternotomy for aortic valve replacement. Twenty-six studies were selected, with 4586 patients with aortic valve replacement (2054 ministernotomy, 2532 full sternotomy). There was no difference in mortality (odds ratio 0.71, 95% confidence interval 0.49-1.02). Ministernotomy had longer crossclamp and bypass times (weighted mean difference 7.90 minutes, 95% confidence interval 3.50-10.29 minutes, and 11.46 minutes, 95% confidence interval 5.26-17.65 minutes, respectively). Both intensive care unit and hospital stays were shorter with ministernotomy (weighted mean difference -0.46 days, 95% confidence interval -0.72 to -0.20 days, and -0.91 days, 95% confidence interval -1.45 to -0.37 days, respectively). Ministernotomy had shorter ventilation time and less blood loss within 24 hours (weighted mean difference -2.1 hours, 95% confidence interval -2.95 to -1.30 hours, and -79 mL, 95% confidence interval -23 to 136 mL, respectively). Randomized studies tended to demonstrate no difference between ministernotomy and full sternotomy. Rate of conversion from partial to conventional sternotomy was 3.0% (95% confidence interval 1.8%-.4%). Ministernotomy can be performed safely for aortic valve replacement, without increased risk of death or other major complication; however, few objective advantages have been shown. Surgeons must conduct well-designed, prospective studies of relevant, consistent clinical outcomes to determine the role of ministernotomy in cardiac surgery.
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              Minimally invasive mitral valve operations.

              A technique for mitral valve operations is described in which exposure is performed through a small right parasternal incision. Via a transseptal approach, excellent exposure to the mitral valve is obtained, allowing surgical correction of the diseased valve.
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                Author and article information

                Journal
                Kardiochir Torakochirurgia Pol
                Kardiochir Torakochirurgia Pol
                KITP
                Kardiochirurgia i Torakochirurgia Polska = Polish Journal of Cardio-Thoracic Surgery
                Termedia Publishing House
                1731-5530
                1897-4252
                30 June 2015
                June 2015
                : 12
                : 2
                : 103-110
                Affiliations
                [1 ]Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
                [2 ]Cardiac Surgery Department, Military Institute of Medicine, Warsaw, Poland
                Author notes
                Address for correspondence: Marcin Kaczmarczyk, MD, 20 B/7 Rolna St., 40-555 Katowice, Poland. phone: +48 601 561 100. e-mail: m21kaczmarczyk@ 123456wp.pl
                Article
                25467
                10.5114/kitp.2015.52850
                4550017
                Copyright © 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Cardiac Surgery

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